./^, 


KD5"^5 


U^45 


tntI)e€ttpotlmgork 

CoUege  of  ^tjpgictans;  anti  ^urgeonsf 

Hiiirarp 


^ 


V 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/warsurgeryofnervOOunit 


WAR  SURGERY 
OF  THE  NERVOUS  SYSTEM 


A   DIGEST   OF  THE    IMPORTANT  MEDICAL 

JOURNALS  AND  BOOKS  PUBLISHED  DURING 

THE  EUROPEAN  WAR 


COMPILED  BY  THE  DIVISION  OF  BRAIN  SURGERY 
SECTION  OF  SURGERY  OF  THE  HEAD 


OFFICE  OF  THE  SURGEON  GENERAL 
War  Department  :  Washington,  D.  C,  1917 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 

1917 


L',  ,   f 


Vt«4?( 


TABLE  OF  CONTENTS. 


Page. 

Preface 5 

Chapter  I.— HEAD. 

Part  1 .  Fractures  of  the  skull 7 

2.  Meninges,  ependyma,  and  brain 27 

3.  The  vestibular  apparatus  in  the  diagnosis  of  intracranial  disease 85 

4.  Abstracts  from  foreign  war  literature Ill 

Chapter  II.— SPINE. 

Part  1.  Sui'gical  anatomy  of  vertebral  column  and  spinal  cord 205 

2.  Normal  and  pathological  physiology  of  the  spinal  cord 213 

3.  Localization  of  motor,  sensory,  and  reflex  functions  in  the  different 

segments  of  the  spinal  cord 218 

4.  The  symptomatology  of  spinal  disease 222 

5.  The  symptoms  of  spinal  disease  at  different  levels  and  in  different 

regions  of  the  cord : 229 

6.  The  operation  of  laminectomy 234 

7.  Abstracts  from  foreign  war  literatiu'e 247 

Chapter  III.— PERIPHERAL  NERVES. 

Part  1.  Diseases  of  the  peripheral  nerves 301 

2.  Abstracts  from  foreign  war  literature 336 

3 


PREFACE. 


This  manual  represents  an  atte)ni)t  to  collect,  digest,  and  arrange 
in  orderly  form,  the  literature  of  war  surgery  of  the  skull,  brain, 
spine,  spinal  cord,  meninges,  and  peripheral  nerves,  from  August, 
1914,  to  August,  1017.  The  sources  of  supply  were  the  English,  (mer- 
man, and  French  Aveekly,  monthly,  and  quarterly  medical  journals, 
and  those  foreign  treatises  dealing  with  war  surgery  as  practiced 
and  observed  during  the  present  conflict. 

The  scheme  adopted  has  been  based  largely  on  the  plan  of  the 
collective  abstract.  It  was  thought  wise  to  furnish  fairly  full  ab- 
stracts, in  order  both  to  avoid  unw'arrantable  dogmatism,  and  also  in 
order  to  allow  the  reader  free  scope  of  personal  interpretation.  For 
this  latter  reason  also,  the  editor  has  refrained  both  from  extended 
critique  and  from  attempting  generalized  conclusions,  by  way  of 
summary. 

Xo  abstracts  on  the  subject  of  Roentgenology  have  been  furnished 
for  the  reason  that  special  schools  are  equipping  men  for  this  work. 
The  following  are  satisfactory  references:  A.  G.  Straw,  Arch,  of 
Radiol,  and  Electrother,  May,  19|T,  p.  393 ;  W.  Oram,  At^oh.  of 
Radiol,  and  Electrother.  February,  1917,  p.  277;  H.  E.  Gamlem, 
Arfih.  of  Raddol.  and  Electrother^  November.  1916,  p.  175;  Gage, 
Arch,  of  Radiol,  and  Electrother.,  June,  1917,  p.  1 ;  E.  Skinner,  Amer. 
Jour.  Roent..,  June,  1917,  p.  350;  George  H.  Makins,  Brit.  Jour,  of 
Surg.,  June  16,  1917,  p.  803. 

Since  the  war  hospitals  may  not  be  Avell  supplied  with  books,  we 
have  introduced  the  abstracts  w'ith  selections  from  standard  text- 
books, so  that  the  reader  of  the  manual  might  be  always  in  close 
touch  with  fundamentals.  For  the  brain,  we  have  used  the  chapters 
from  Keen's  Surgery  w^ritten  by  Dr.  Harvey  Cushing,  and  chapters 
from;  Dr.  Isaac  H.  Jones's  forthcoming  book  on  Equilibrium  and 
Vertigo.  For  the  spine  w^e  have  used  selected  chapters  from  Dr. 
C.  A.  Elsberg's  book  on  Diseases  of  the  Spinal  Cord  and  its  Mem- 
branes, and  Dr.  Charles  H.  Frazier's  volume  (in  press)  on  Surgery 
of  the  Spine,  and  for  peripheral  nerves  we  have  selected  the  chapter 
on  peripheral  nerves,  wn-itten  by  Dr.  Gordon  M.  Holmes  for  Osier's 
Modern  Medicine. 

The  use  of  the  phrase  *'  war  surgery  "  must  be  taken  with  a  good 
deal  of  qualification,  lest  one  fall  into  the  error  of  thinking  of  this 
type  of  work  as  separate  and  distinct  from  the  surgery  of  civil  life. 

5 


6  WAR    SUEGEEY    OF    THE    NEEVOUS   SYSTEM. 

As  a  matter  of  fact  the  surgical  principles  governing  both  are  in 
large  part  exactly  the  same.  The  laws  of  ballistics,  trench  life,  the 
terrain  of  the  battle  field,  the  problems  of  transport,  and  numerous 
other  incidentals  serve  to  modif}'  established  principles  of  surgery, 
but  not.  more  than  that.  Indeed  nothing  demonstrates  more  clearly 
the  truth  of  this  statement  than  the  fact  that  war  surgery  makes  such 
free  use  of  those  aids  Avhich,  in  civil  surgery,  are  indispensable  for 
both  the  laying  down  and  following  out  of  principles— bacteriolog}% 
serology,  roentgenology,  and  the  general  routine  of  clinical  mi- 
croscopy. 

Thanks  are  extended  to  the  editor  of  Surgery  Gynecology  and 
Obstetrics  for  the  permission  to  use  abstracts  from  this  journal.  As 
a  result  of  this  much-appreciated  courtesy  Ave  Avere  able  to  complete 
an  emergency  task  within  a  necessarily  verj^  short  time  limit.  Thanks 
are  also  extended  to  J.  B.  Lippincott  Co.  for  the  privilege  of  quoting 
from  Dr.  Isaac  H.  Jones's  forthcoming  book,  Equilibrium  and  Ver- 
tigo: to  W.  B.  Saunders  Co.  for  the  privilege  to  use  Dr.  Harvey 
Cushing's  contribution  to  Surgery,  Its  Principles  and  Practice,  edited 
by  William  Williams  Keen^  M.  D.,  and  Diseases  of  the  Spinal  Cord 
and  Its  Membranes  by  Charles  A.  Elsberg,  M,  D. ;  to  Lea  &  Febigei- 
for  the  privilege  to  use  Dr.  Gordon  Holmes's  contribution  to  Modern 
Medicine,  edited  by  Sir  William  Osier,  M.  D.,  and  Thomas  McCrae. 
M.  D. :  and  finally,  to  D.  Appleton  &  Co.,  for  the  privilege  to  use  the 
chapter  from  Dr.  Charles  H.  Frazier's  forthcoming  volume  on  Dis- 
eases of  the  Spinal  Cord.  We  feel  a  deep  sense  of  obligation  to  all 
these  authors,  from  whom  we  have  draAvn  so  freely.  It  was  unfortu- 
natel}^  impossible  to  communicate  directly  with  Dr.  Cushing  or  with 
Dr.  Holmes,  in  order  to  secure  from  them  an  expressed  willingness, 
which  Ave  Avere  sure  they  Avould  accord  us  if  time  permitted. 


Chapter  I. 
SURGERY  OF  THE  HEAD. 


(Parts  1-2  from  Dr.  Hakvey  Cushing's  contribution  to  Surgery,  Its  Principles 
and  Practice.     Edited  by  W.  W.  Keen,  M.  D. ;  published  by  W.  B.  Saunders 

Company.  I 


Part  1. 

FRACTURES  OF  THE  SKULL. 

Terminology. — The  skull  may  be  said  to  be  fractured  in  distinction 
to  its  being-  wounded  when,  as  the  result  of  a  blow,  it  becomes  cracked 
or  broken  into  more  or  less  separate  pieces.  These  injuries  are  classi- 
fied in  a  variety  of  ways: 

(a)  According  to  the  mechanism  of  their  production. 
(h)   According  to  the  presence  or  absence  of  a  communicating 
wound. 

(c)  According  to  the  form  assumed  bj^  the  fragments. 

(d)  According  to  their  situation. 

(a)  Depending  on  the  mechanical  factors  at  work  in  their  pro- 
duction, they  are  distinguished  as  (1)  bursting  fractures  and  (2) 
fractures  due  to  local  depression  or  indentation — so-called  bending 
fractures.  In  the  case  of  fractures  the  result  of  penetration  by  mod- 
ern high- velocity  projectiles  a  further  mechanical  element  comes  into 
play,  producing  expansion  fractures  through  the  explosive  force  of 
hydrodynamic  action. 

(b)  Fractures  are  ojjen  or  compound  when  they  are  exposed  by 
a  wound  of  the  overlying  soft  parts;  they  are  simple  or  closed  when 
the  soft  tissues  covering  them  remain  intact. 

(c)  According  to  their  form  they  are  distinguished:  As  linear  or 
fissured  fractures  when  the  bone  is  merely  cracked  without  displace- 
ment ;  as  a  fracture  by  diastasis  when  there  is  a  simple  separation  of 
the  sutures;  as  cormninuted  or  fragmented,  fractures  when  the  lines 
of  fracture  intersect,  so  as  to  isolate  separate  particles  of  bone;  as 
depressed  fractures  when  fragments  of  bone,  whether  of  the  entire 
cranial  thickness  or  of  the  inner  table  alone,  are  driven  below  their 
spherical  level;  as  perforating  fractures  or  fractures  loith  loss  of  sub- 

7 


8  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

stance  when  they  are  the  result  of  punctured  wounds  or  when  the 
fragments  at  the  seat  of  the  penetration  have  been  carried  away, 
leaving  a  defect,  as  is  the  case  in  most  penetrating  bullet  wounds. 
And  of  these  chief  varieties  many  subdivisions  may  be  made. 

{d)  Lastly,  depending  roughly  on  their  anatomical  situation,  they 
are  distinguished  as  fractures  of  the  lyase  and  fractures  of  the  vault, 
and  although  the  two  are  often  combined  they  may  exist  separately 
and  have  different  characters.  Thus,  fractures  of  the  base  are  usually 
linear  and  their  fragments,  if  comminuted,  are  rarely  displaced,  for 
the  base  is  much  less  accessible  to  direct  injury;  hence,  fractures  there 
are  usually  the  indistinct  result  of  violence  applied  elsewhere.  On  the 
other  hand,  the  vault  is  directly  exposed  to  injury  and  local  comminu- 
tion with  dislocation  of  fragments  is  common,  and  as  the  bone  is 
thick  and  has  two  determinable  layers  there  are  special  influences 
which  modify  the  character  of  the  fragmentation. 

{a)  The  mechanism  of  fractures — Bending,  bursting,  and  expansile 
fractures. — Regarded  as  a  hollow  shell  of  bone  which  possesses  elas- 
ticity sufficient  to  rebound  when  dropped,  the  cranium  must  needs 
differ  from  all  other  bones  of  the  skeleton  in  the  mechanism  of  its 
injuries.  Certain  of  the  physical  laws  which  explain  the  peculiar 
form  assumed  by  these  injuries  are  known  to  us;  others  are  still  in 
dispute,  and  though,  from  a  strictly  clinical  point  of  view,  of  chief 
importance  is  the  knowledge  that  under  certain  conditions  breaks 
occur  in  a  certain  manner  and  lead  to  certain  complications,  we  nat- 
urally search  for  an  explanation  of  the  reason  why  they  so  occur, 
even  though  this  information  may  in  no  Avise  affect  our  diagnosis, 
prognosis,  or  treatment. 

Teevan,  Wahl,  Rauber,  Felizet,  Aran,  Bohl,  Bruns,  Bergmann. 
Kocher,  and  a  host  of  others  have  undertaken  clinical  and  experi- 
mental investigations  directed  toward  the  elucidation  of  the  under- 
lying principles  governing  cranial  fractures. 

We  must  take  into  consideration  the  double  effect  of  an  impact, 
for  the  blow  may  produce  (1)  disturbances  which  are  direct  and 
chiefly  of  local  consequence,  and  (2)  those  which  are  indirect  and  lead 
to  solutions  of  continuitj'^  at  a  distance.  Setting  aside  for  the  moment 
its  irregularities  and  considering  the  skull  to  be  an  elastic  globe,  an 
impact  will  momentarily  lessen  its  diameter  in  line  of  the  blow,  and 
force  nearer  together  the  point  or  pole  of  impact  and  the  point  on 
the  sphere  diametrically^  opposite.  As  the  impact  forces  the  poles 
together  it  will  at  the  same  time  bulge  out  the  sides  of  the  sphere  and 
thus  increase  the  equatorial  circumference  and,  in  a  lesser  degree,  the 
circumference  of  all  the  other  circular  planes  which  lie  perpendicular 
to  the  polar  diameter.  If  the  distortion  following  the  impact  is  in- 
considerable the  skull,  owing  to  the  elastic  rebound,  will  resume  its 
former  shape  unimpaired.     If  the  distortion,  on  the  other  hand,  is 


FRACTURES   OF   THE   SKULL,  9 

SO  great  as  to  overcome  the  molecular  cohesion  of  the  bony  particles, 
they  will  be  disrupted.  This  may  take  place  (1)  as  a  rupture  or 
bursting  of  the  bone  in  parts  remote  from  the  poles  of  impact  where 
cranial  dimensions  have  been  increased  to  the  point  of  overcoming 
tensile  strength  of  the  particles,  and  (2)  as  a  local  indentation  at  the 
pole  of  impact  where  cranial  dimensions  ha\e  been  diminished  to  the 
point  of  overcoming  the  local  resistance  of  the  particles  to  pressure. 
These  two  qualities  of  elasticity' — tensile  strength  and  resistance  to 
pressure — have  been  the  objects  of  special  study  hy  Eauber,  who  has 
shown  that  resistance  to  pressure  is  a  third  greater  than  tensile 
strength.  This,  however,  does  not  mean  that  fractures  are  less  likely 
to  occur  at  the  pole  of  impact  than  at  a  distance,  for  other  factors 
come  into  play. 

Local  character  of  injuries  through  bending. — These  fractures  usually 
result  from  the  sharp  impact  of  a  body  with  a  comparatively  small 
surface.  Such  a  blow  expends  its  force  quickly  and  a  rebound  occurs 
before  the  form  of  the  skull,  as  a  whole,  has  been  sufficiently  altered 
to  produce  lesions  at  a  distance.  At  the  pole  of  impact  the  bone  is 
broken  and  the  displaced  fragments  do  not  resmne  their  former 
position. 

In  spite  of  its  greater  thickness  and  vaulted  construction  fractures 
of  this  sort  are  more  common  on  the  exposed  calvarium  than  at  the 
inaccessible  base.  The  character  of  the  lesion,  furthermore,  is  in- 
fluenced by  the  structural  peculiarity  of  the  bone;  namely,  its  two 
dense  tables  separated  by  a  spongy  diploe.  Owing  to  this,  an  in- 
dentation which  leads  to  a  bending  fracture  will  cause  the  inner  table 
to  splinter  and  give  way  before  the  outer.  In  consequence  we  not 
infrequently  find  fractures  limited  to  the  inner  table — a  circum- 
stance known  even  to  the  earliest  writers  in  medicine,  who  explained 
the  phenomeon  on  the  supposition  that  the  inner  table  was  more 
fragile  or  brittle  than  the  outer  one,  hence  the  "  vitreous  "  surface. 
Xot  until  Tee  van's  studies  was  the  process  satisfactorily  explained 
on  the  ground  of  tensile  strength  or  cohesion  of  particles  on  the 
one  hand  and  of  resistance  to  pressure  on  the  other.  There  is  no 
simpler  illustration  than  the  oft-used  one  of  a  green  stick  broken 
across  the  knee.  The  cranial  impact  leads  to  a  local  indentation, 
which  tends  to  pull  apart  the  particles  comprising  the  inner  table 
and  to  drive  together  those  of  the  outer.  In  certain  rare  cases  the 
process  may  be  reversed  and  the  outer  table  alone  sutler ;  this  implies 
a  blow  from  within.  Both  Teevan  and  Bergmann  have  given  in- 
stances of  such  lesions;  thus,  after  traversing  the  cranial  cavity,  a 
spent  bullet  may  strike  the  inner  surface  of  the  skull  and  fracture 
the  overlying  outer  table  alone. 

If  the  force  of  the  blow  has  been  expended  by  the  time  the  inner 
tJible  gives  way,  it  alone  suffers  fracture:  if  it  continues,  the  outer 


I'O  WAR   SUKGEEY    OF    THE    NERVOUS    SYSTEM. 

gives  way  as  Avell,  but  in  the  latter  case  it  is  always  to  be  borne  in 
mind  that  the  inner  table  splinters  over  a  wider  area  than  the  outer. 
A  lesion  Avhich  is  limited  to  the  inner  table  alone  can  only  occur 
in  a  skull  well  provided  with  diploe,  and  consequently  in  infancy 
and  old  age  the  bone  will  usually  give  way  throughout  its  entire 
thickness  at  the  same  moment. 

These  bending  fractures  may  be  associated  Avith  little  or  no  dis- 
placement of  fragments;  they  may,  on  the  other  hand,  lead  to  a 
marked  depression  whose  floor  is  made  up  of  firmly  wedged  frag- 
ments from  the  two  tables.  They,  furthermore,  are  usually  bounded 
by  an  irregular  circular  fissure,  into  which  lines  of  fracture  radiate 
from  the  central  point  of  impact.  An  excellent  example  of  such  a 
circular  fracture  from  bending  occurs  among  the  comparatively  rare 
instances  of  this  form  of  fracture  at  the  base,  when,  as  the  result  of  a 
fall  upon  the  buttock  the  impact  is  transmitted  to  the  occipital 
bone  through  the  spinal  column,  and  the  circular  fracture  more  or  less 
clearly  surrounds  the  foramen  magnum. 

Distant  effects  of  injuries  through  bursting. — A  diffuse  blow  from 
a  fiat  surface  is  prone  to  cause  effects  at  a  distance,  just  as  a  concen- 
trated one  from  a  small  body  is  apt  to  produce  local  effects.  A  burst- 
ing fracture  of  typical  form,  comparable  to  the  lesions,  which  Von 
Bruns  has  produced  experimentally  by  compressing  skulls  in  a  vise  tc 
the  point  of  fracture,  was  cited  in  the  clinical  note  given  above,  but 
it  is  unusual  for  the  head  to  be  caught  and  squeezed  in  this  way.  An 
analogous  injury  may  occur  when,  lying  on  a  hard  surface,  it  is 
struck  by  a  falling  body,  though  a  violent  blow  against  one  side  of 
the  cranium  alone — the  head  itself  usually  being  the  moving  force — 
is  the  more  common  method.  Though  the  striking  surface,  favorable 
for  a  bursting  effect,  should  be  a  fiat  one,  it  is  common  enough  for 
some  forms  of  impact,  which  produce  primarih^  an  indentation,  to 
cause  a  bursting  of  the  skull  as  well,  in  case  there  is  no  immediate 
rebound  and  if  the  force  exerted  be  sufficient.  Thus,  we  often  find 
meridional  fissures  which  radiate  from  a  local  bending  fracture  situ- 
ated at  the  pole  of  impact  or,  indeed,  even  in  the  absence  of  a  polar 
fracture. 

Thus,  most  fissured  fractures  are  an  expression  of  the  indirect  or 
bursting  effect  of  a  blow,  and  inasmuch  as  the  base  of  the  skull  is 
more  fragile  than  the  vault  these  fissures  occur  most  readily  in  this 
region. 

Having  oftentimes  no  apparent  connection  with  any  lesion  at  the 
point  of  impact  they  naturall}^  are  spoken  of  as  the  indirect  result 
of  violence. 

The  view  that  these  injuries  at  a  distance  are  due  to  the  effects  of 
a  counterinjury  or  contrecoup — a  term  introduced  by  French  sur- 
geons in  the  latter  half  of  the  eighteenth  century — is  one  which  re- 
mains popular,  though  it  has  been  shown  to  be  mechanically  wrong. 


FRACTURES    OF    THE    SKULL,  11 

We  leai'ii  from  thei^e  obser\  iilidns  that  bursting  fractures  need 
not  be  associated  with  any  disphicement  of  l^one.  but  that  linear 
cracks  occur  wliich  haAe  a  tendency  to  lain  into  the  nearest  weak 
portion  of  the  cranial  base.  These  cracks  oi-  fissures  enter  the  middle 
cranial  fossa-  more  often  than  the  anterior  or  posterior,  and  it  is 
Walton's  view  that  they  often  seek  out  the  sella  turcica,  which  pre- 
sumably is  the  weakest  point  of  all. 

There  are  factors  other  than  those  already  mentioned  which  are 
thought  to  modify  the  direction  of  these  cracks  from  bursting. 
Among  them  are  the  foramina  and  the  sutures.  Whether  the  frac- 
tures tend  to  seek  or  to  avoid  the  l)asal  foramina  is  a  matter  of 
dispute.  It  seems  to  depend  upon  the  relative  strength  of  the  rim 
of  the  foramen  and  the  neighboiing  bone.  When  the  rim  is  thick- 
ened and  strong,  even  so  large  a  defect  as  the  foramen  magnum 
need  not  be  an  evidence  of  local  weakness:  no  more  need  a  trephine 
opening  in  the  vault  in  any  wa}^  weaken  the  elastic  strength  of  the 
cranial  sphere.  Nevertheless,  there  are  certain  foramina  which  are 
apt  to  be  involved,  as  the  posterior  lacerated  space,  the  foramen 
ovale,  and  the  facial  and  acoustic  foramina. 

The  sutures,  on  the  other  hand,  often  serve  to  deflect  fissures  from 
the  direction  which  they  should  have  taken  by  mechanical  laws. 
This  is  especially  true  for  the  skulls  of  young  individuals.  (See 
Fractures  by  Diastasis.) 

The  explosive  effect  of  hydrodynamic  force. — The  introduction  of 
the  modern  firearm,  with  its  peculiar  nondeforming,  hard-mantled 
projectile,  has  brought  an  entirely  new  element  into  the  mechanism 
of  penetrating  gunshot  wounds,  particularly^  those  involving  the 
cranium.  It  has  been  made  the  subject  of  special  study  by  Kocher, 
von  Bruns,  Coler.  and  Schjerning.  When  such  a  projectile,  with 
its  extreme  initial  velocity  and  great  penetrating  power,  traverses 
the  incompressible  semifluid  brain,  inclosed  as  it  is  within  a  solid 
covering,  it  exerts  an  enormous  explosive  (hydrodynamic)  force 
against  the  inner  cranial  surface.  W^ere  the  cranial  chamber  empty 
a  simple  penetrating  wound  of  entrance  and  exit  would  result,  but, 
being  full,  the  tremendous  force  is  transmitted  against  all  points 
of  its  inner  surface,  and  consequently''  its  walls  become  shattered 
into  fragments. 

(h)  Clinical  varieties  of  fracture. — By  the  qualification  simple  or 
compound  or,  possibly  better,  open  or  closed^  we  indicate,  as  in 
skeletal  lesions  elsewhere,  that  the  fracture  is  covered  by  intact  soft 
parts  or  commvmicates  Avith  the  air  through  an  external  wound. 
The  distinction  is  po&sibly  of  less  vital  significance  than  formerly 
and,  indeed,  here  more  often  than  in  any  other  part  of  the  body  we 
deliberately,  by  operati^■e  explorations,  turn   simple  fractures  into 


12  WAR   SUEGERY   OP   THE    NERVOUS   SYSTEM. 

open  ones  for  the  replacement  of  dislocated  fragments  or  to  avoid 
other  complications.  In  compound  fractures  of  the  base,  however, 
Ave  are  almost  as  helpless  in  the  prevention  of  infection  as  were  our 
predecessors;  for  when  these  injuries  communicate  with  the  ear.  the 
pharynx  or  the  sinuses  accessory  to  the  nasal  cavity,  Avhere  patho- 
genic organisms  lurk,  a  doorway  which  we  can  not  reach  is  opened 
to  infection.  A  compound  fracture  of  the  base  from  other  cause 
than  bursting  is  unusual,  though  it  may  occur  when  a  weapon,  a 
bullet,  or  other  missile  has  entered  the  skull  from  below.  In  such  a 
case  careful  surgical  cleansing  and  drainage  is  demanded. 

Fractures  according  to  their  form. — Fissured  or  linear  fractures,  as 
we  have  seen,  are  the  usual  result  of  bursting;  they  tend  to  take  a 
meridional  course,  radiating  from  the  pole  of  impact,  and.  further, 
owing  to  its  structural  weakness,  they  more  commonly  occur  at  the 
base.  When  the  skull  resumes  its  former  shape,  after  the  moment 
of  deformation  which  causes  the  bones  to  spring  apart,  the  fissure 
will  close  tightlj^,  provided  there  has  been  no  associated  fragmenta- 
tion. At  the  moment  of  separation  of  a  fissure,  substances  like  hair, 
portions  of  headgear,  or  pieces  of  the  missile  which  inflicted  the  bloAv 
may  either  be  introduced  wholly  into  the  cranial  chamber  or  be 
caught  in  a  vicelike  grip  when  the  edges  again  snap  together.  It 
acts  like  the  "  meridional  "  crack  in  a  child's  hollow  rubber  ball,  which 
gapes  when  its  poles  are  compressed. 

A  fissured  fracture  may  occur  as  a  single  linear  crack,  it  may  fork 
or  branch,  or  there  may  be  multiple  fissures  radiating  from  the  point 
of  impact.  A  simple  linear  fissure  may  close  so  snugly  as  to  be  diffi- 
cult of  detection  even  on  direct  exposure.  Attention  may  be  called 
to  it,  hoAvever,  by  the  extrusion,  along  the  closely  approximated 
edges,  of  fine  drops  of  blood.  After  death  this  does  not  help  and  at 
autopsy  fissures  may  escape  other  than  the  closest  scrutiny.  In  other 
instances,  whether  from  interposition  of  tissue  or  from  some  dis- 
location of  fragments,  an  extensive  meridional  crack  may  continue 
to  gape.  Such  a  condition,  especially  when  the  fissure  has  included 
the  vault,  may  be  detected  by  percussion,  or  Avhen  the  head  has  been 
shaved,  by  auscultation  combined  with  percussion,  the  blow  eliciting 
a  "  hollow-cask  "  sound.  Furthermore,  there  will  be  tenderness  along 
the  line  of  fracture,  though  this  is  of  little  aid  in  unconscious  pa- 
tients. It  is  to  be  remembered  that  sutures  are  often  mistaken  for 
fissures. 

Linear  fractures,  though  simple  in  themselves,  are  especially  prone 
to  be  accompanied  by  intracranial  complications,  for  their  very 
presence  indicates  a  diffuse  bloAV  the  effect  of  Avhich  is  usually  Avide- 
spread.  Hence  cerebral  contusions  are  common.  The  fissures  often 
run  across  the  meninseal  grooves  and  lead  to  extradural  extravasa- 


FRACTURES   OP   THE    SKULL.  13 

tions  and  more  or  less  subdural  hemorrhage  is  the  rule  in  the  linear 
fractures  of  the  base. 

The  treatment,  therefore,  resolves  itself  into  the  treatment  of  the 
complications  rather  than  of  the  fracture,  viz,  the  evacuation  of  the 
clot  in  an  extradural  hemorrhage;  the  drainage  of  the  cerebrospinal 
space  if  subdural  hemorrhage  or  edema  has  been  sufficient  to  cause 
bulbar  symptoms. 

Fractures  by  diastasis. — Linear  fractures  may  be  deflected  into  one 
of  the  sutures,  due  to  the  fact  that,  before  the  complete  obliteration 
which  they  may  undergo  late  in  life,  they  offer  less  resistance  to  the 
cranial  deformation  than  does  the  bone  elsewhere.  In  the  young 
the  lesion  may  occur  as  a  true  separation  of  the  bones.  I  have  seen  at 
operation  upon  a  child  of  12.  whose  head  some  days  before  had 
been  caught  and  laterally  squeezed,  a  simple  diastasis  of  the  coronal 
suture,  which  had  torn  the  dura,  leading  to  the  escape  of  cerebro- 
spinal fluid  under  the  scalp  (spurious  meningocele)  ;  at  no  time 
had  there  been  any  cerebral  symptoms.  In  the  adult,  on  the  other 
hand,  the  process  is  necessarily  more  than  a  simple  diastasis,  for 
union  is  so  firm,  owing  to  the  close  dovetailing  of  the  irregular  bony 
margins,  that  separation  of  the  sutures  can  not  occur  otherwise  than 
by  a  break. 

Comminuted  fractures  are  those  characterized  by  more  or  less  frag- 
mentation or  splintering.  The  comminution  may  be  confined  to 
the  area  of  impact  or  the  entire  cranium  may  be  broken  into  pieces. 
Being  a  common  result  of  local  deformation  or  inbending  at  the 
point  of  injury,  they  are  usually  situated  on  the  vault  and  depend 
for  their  production  on  the  character  not  only  of  the  blow  (a  sharp 
one  with  quick  rebound)  but  also  of  the  striking  body. 

From  the  standpoint  of  the  bony  lesion  itself  they  are  more  serious 
than  linear  fractures,  owing  to  the  usual  displacement  of  fragments — ■ 
fractures  with  depression.  Extensive  comminution,  however,  may 
occur  with  little,  if  any,  dislocation  of  the  broken  pieces.  We  may, ' 
furthermore,  in  the  elastic  skulls  of  infants  have  depression  with  no 
comminution  or,  indeed,  with  a  total  absence  of  fracture.  Finally, 
in  certain  rare  cases,  fracture  may  occur  with  actual  elevation  of  a 
fragment.  These  effects,  however,  are  unusual;  comminution  and 
depression  commonly  go  hand  in  hand.  Hence  they  will  be  con- 
sidered together. 

The  comminution  and  depression  may  affect  the  inner  table  alone 
or  both  tables,  in  which  case  the  fragments  may  consist  of  the  entire 
thickness  of  the  skull  or,  in  diploetic  skulls,  of  the  separated  tables. 
When  thus  separated  the  fragmentation  of  the  inner  is  always  more 
widespi-ead  than  that  of  the  outer.  The  fragments  may  form  a  cup- 
.shaped  depression,  often  termed  by  English  writers  "  pond  fracture," 


14  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

or  the}'  may  become  tilted  at  the  periphery  and  slip  imder  the  intact 
cranial  edge.'  We  thus  have  perrpherul  or  central  depressions. 

From  the  pole  of  impact  in  comminuted  fractures  there  are  often 
numerous  radiating  or  meridional  fissures;  these  in  turn  are  often 
connected  by  zonal  lines  of  fracture,  like  the  connecting  strands  of  a 
spider's  web ;  and  in  these  cases  the  farther  from  the  point  of  impact, 
the  farther  apart  are  the  zonal  lines,  and  consequently  the  larger  the 
fragments.  When  comminution  is  the  result  of  diffuse  blows,  as  in 
the  skull  of  the  "  butting  "  negro  in  the  Surgeon  General's  Museum, 
or  when  it  follows  falls  from  a  great  height,  irregular  fragmentation, 
like  a  broken  eggshell,  may  occur,  with  fissures  having  no  definite 
configuration. 

Almost  all  punctured  or  penetrating  wounds  are  accompanied  by 
more  or  less  local  fragmentation,  with  depressions,  which  particu- 
larly affects  the  inner  table. 

Depressed  fragments  may  heal  in  place  and  their  irregularities 
become,  in  the  course  of  time,  largely  smoothed  off. 

Perforating  fractures  are  due  to  cuts,  to  stab  wounds,  to  the  ]Dene- 
tration  of  sharp  tools  which  have  fallen  from  a  height,  to  the  blow  of 
a  pick,  the  thrust  of  a  bayonet,  and  what  not.  They  are  associated 
with  more  or  less  fissuring,  with  fragmentation,  and  Avith  depression 
of  fragments,  especially  of  those  broken  from  the  inner  table  about 
the  margin  of  the  wound.  Their  course,  diagnosis,  complications, 
and  treatment  do  not  differ  materially  from  that  of  wounds  of  the 
skull  (p.  63),  unassociated  with  fracturing,  though  produced  by  simi- 
lar agencies.  When  a  portion  of  bone  has  been  carried  away,  leav- 
ing a  defect,  they  are  called  fractures  with  loss  of  substance. 

One  particular  group  of  perforating  fractures  deserves  special  con- 
sideration; namely,  those  which  are  the  result  of  wounds  from  fire- 
arms. 

Grunshot  fractures.— In  their  simplest  form  these  are  perforating 
fractures  \A'hich  pi'ocluce  a  circular  loss  of  substance.  When  the  re- 
sult of  a  Avound  at  short  range  from  the  modern  small  arm,  we  have 
seen  that  the  skull  may  be  burst  outward  by  the  explosive  action  of 
hydrodynamic  pressure.  We  have  learned,  too.  that  these  are  com- 
pound or  open  fractures;  that  they  are  aluiost  always  comminuted 
ones  with  some  depression  of  fragments:  and,  finally,  that  they  often 
lead  to  sepsis,  hemorrhage,  or  other  intracranial  lesions,  which  make 
of  them  a  particularly  dangerous  and  crippling  form  of  injury. 

There  are,  however,  other  types  of  gunshot  fracture  less  serious, 
since  they  are  nonperf orating.  Thus,  the  direct  impact  of  a  heavy 
spent  ball  may  fissure  or  indent  the  skull  without  producing  more 
than  a  bruise  of  the  scalp.  Again,  a  bullet  may  pass  through  the 
scalp  and  graze  the  A'ault  in  a  tangential  direction  without  penetra- 
tion, or  it  may  furroAv  the  bone,  scooping  out  a  gutter  in  the  outer 


FRACTURES    OF    THE    SKULL,  15 

table  alone  or  Ivaviiig-  a  defect  of  the  entire  cranial  thickness.  The 
lateral  force  exerted,  during  its  rapid  flight,  by  the  modern  liigh- 
velocity  projectile  is  sufficient  to  comminute  the  skidl,  even  if  it  be 
merely  grazed,  so  that  only  in  those  localities  where  the  bone  is  thick 
and  porous  or  contain  air  cells  Avould  it  be  likely  to  escape  consider- 
able local  fragmentation  from  such  a  tangential  wound.  For  the 
same  reason  fractures  of  the  base  may  occur  when  a  bullet  traverses 
the  shell-like  bones  comprising  the  under  surface  of  the  skull  without 
actually  penetrating  the  cranial  chamber;  and.  further,  bullets  may 
become  lodged  in  the  thicker  parts  of  the  cranial  wall  and  produce 
more  or  less  local  comminution  Avithout  actually  entering  the  cavity. 

The  wound  of  the  bone,  as  we  have  seen,  may  show  nothing  more 
than  a  clean-cut  circular  or  oval  loss  of  substance,  but  it  is  the  rule 
for  the  wounds  both  of  entrance  and  exit,  in  case  they  occur  in  bones 
containing  diploe,  to  show  the  particular  cliaracteristics  of  punctured 
fractures;  that  is,  to  have  a  more  or  less  splintered  margin,  particu- 
larly of  the  table  which  has  been  last  penetrated — the  inner  table  for 
the  wound  of  entrance,  the  outer  table  for  that  of  exit.  Hence,  when 
there  is  a  loss  of  substance  due  to  the  actual  carrying  away  of  frag- 
ments, the  circumference  of  the  defect  will  be  greater  on  the  side 
from  which  the  missile  has  emerged,  whether  it  be  wound  of  entrance 
or  exit — a  matter  often  of  medicolegal  importance.  Furthermore, 
meridional  fissures  are  apt  to  radiate  from  the  wounds  of  impact, 
and  these  meridians  in  turn  are  often  joined  by  circular  fissures  on 
zonal  planes. 

The  damage  from  perforating  bullets  depends  partly  upon  the 
physical  properties  of  the  missile  and  partly  upon  the  speed  with 
which  it  is  traveling.  There  is  great  difference,  therefore,  between 
the  effects  of  the  soft,  leaden  bullet  discharged  from  a  revolver  and 
that  of  the  modern  conical  projectile  with  its  hard  mantle  and  tre- 
mendous initial  velocity.  The  latter  missiles,  except  near  the  end  of 
their  flight,  rarely  lodge;  the  former  almost  invariably  do. 

Ill  liis  Handhuch  der  Praktischen  Chirurgic,  Bergmann  gave  in  full  the  results 
of  experlmeuts  conducted  by  himself  and  others  upon  wounds  of  the  head  made 
by  the  modern  rifle.  Briefly,  it  may  be  said  that  at  close  range  the  skull  and 
scalp  are  literally  torn  to  pieces  and  the  brain  disorganized ;  that  on  penetra- 
tion at  50  yards  the  scalp  remains  intact,  though  the  skull  is  greatly  com- 
minuted and  brain  tissue  oozes  both  from  the  wound  of  entrance  and  exit;  at 
100  yards  there  occur  zonal  fractures  wliich  tend  to  be  limited  to  the  area 
about  the  wounds  of  entrance  and  exit,  while  meridional  fissures  radiate  from 
these  points,  showing  that  explosive  action  is  still  effective;  at  1.000  yards 
the  zonal  cracks  encircling  the  bullet  holes  disappear,  and  only  the  radial 
fissures  remain;  at  tlie  distance  of  1  mile  the  fissures  largely  disappear,  leaving 
the  two  clean-cut  bullet  holes;  and  not  until  over  li  miles  does  the  projectile 
fail  to  emerge  after  entering  the  skull  on  one  side.  All  this,  of  course,  is  merely 
relative,  for  there  would  be  great  difference,  not  only  in  individual  skulls    but 


16  WAB   SURGERY   OF   THE    NERVOUS   SYSTEM. 

in   the   position   in   whicli   they    were   struck ;    and    it   is,    after   all,    a    matter 
chiefly  of  interest  to  the  military  surgeon. 

On  the  wliole,  these  wounds  in  warfai-e  liave  a  grave  prognosis.  According: 
to  Fischer's  statistics  from  tlie  German  Army  during  the  Franco-Prussian  War, 
45  per  cent  of  8,132  gunshot  injuries  resulted  in  immediate  death,  and  nearly 
one-half  of  those  found  dead  ou  the  held  of  battle  had  wounds  of  the  skull. 

The  gunshot  fractures  which  are  seen  in  civil  life  are  more  apt  to 
result  from  revolver  shots  and  in  orderly  communities  to  be  self- 
infiicted  wounds,  whether  by  accident  or  intent.  Here  again  the  char- 
acter of  the  injury  depends  upon  the  nature  of  the  weapon  and  the 
initial  velocity  of  the  projectile.  Most  of  the  wounds  which  one  sees 
to-day  are  produced  by  soft  bullets  fired  from  the  ordinary  revolver 
with  no  great  initial  momentum;  the  heavier  army  pistols,  on  the 
other  hand,  fire  a  projectile  which  at  near  range  has  the  explosive 
effect  of  a  rifie.  The  soft,  deforming  revolver  bullets  are  apt  to  lodge 
either  in  the  bone  at  the  site  of  entrance  or  somewhere  within  the 
cranial  cavity,  either  at  some  point  in  the  direct  line  of  their  flight 
or,  in  case  the  missile  has  rebounded,  at  some  point  in  a  line  deter- 
mined by  the  angle  of  deflection  from  the  opposite  inner  surface.  At 
times  the  course  of  such  a  deflected  bullet  may  be  mathematical!}^ 
calculated,  but  to-day  the  ,r-rays  give  us  a  more  accurate  means  for 
determining  its  position.  It  may  be  said,  however,  that,  as  a  rule, 
there  is  no  particular  reason  for  its  extraction,  for  in  the  absence  of 
immediate  complications  it  becomes  encapsulated  and,  unless  the  mis- 
sile chance  to  lie  near  the  surface,  the  damage  already  done  will  only 
be  increased  by  meddlesome  attempts  to  locate  and  extract  it. 

The  complications  which  result  from  penetrating  bullet  wounds 
ma}^  be  classified  as  imm-ecUate^  or  those  clue  to  hemorrhage,  com- 
pression, and  destruction  of  tracts ;  intermediate^  or  those  due  to  sep- 
sis; and  late  symptoms  (irritative  and  paralytic),  giving  evidence  of 
the  permanent  damage  done  to  the  cerebral  tissues.  Hemorrhage,  of 
all  the  immediate  symptoms,  is  especially  to  be  dreaded,  as  it  may 
lead  to  rapid  death  from  compression.  In  all  cases  in  which  there  is 
an  increase  in  intracranial  tension  from  efi^used  blood,  the  pressure 
forces  the  disorganized  nervous  tissue  through  the  wounds  of  entrance 
and  exit,  and  the  extruded  particles  of  white  tissue  are  found  mingled 
with  the  blood  which  oozes  from  the  opening.  It  is  not  uncom- 
mon for  cranial  nerves  to  be  injured,  either  by  direct  section  or 
by  implication  in  a  basal  fracture. 

It  is  notorious  that  suicides  often  fail  to  accomplish  their  purpose. 
Brun  has  recorded  32  cases,  of  which  number  16  recovered.  Of 
these  cases  the  wound  of  entrance  was  in  the  right  temporal  region 
sixteen  times,  in  the  left  twice,  in  the  forehead  nine  times,  and  in  the 
mouth  twice.  The  "  temple  "  is  regarded  by  the  laity  as  a  partic- 
ularly'- vulnerable  spot,  which  accounts  for  the  preponderance  of  the 
attempts  in  this  situation.     In  them  oftentimes  the  bullet  merely 


FRACTURp]S    OF    THE    SKULT..  17 

passes  extra-cranially  from  temporal  fossa  to  temporal  fossa,  through 
the  back  of  both  orbits,  cutting  the  optic  nerves  and  leading  to  blind- 
ness— a  sad  penalty  for  a  criminal  act.  Though  unrecorded  in  Brun's 
series,  suicidal  wounds  inflicted  in  the  right  mastoid  region  are  not 
uncommon. 

The  later  complications,  in  case  of  "  recovery,"  are  paralyses,  men- 
tal changes,  epilepsy,  etc.  Thus,  a  patient  was  accidentally  shot 
in  the  mid -line  of  the  forehead  at  the  hair  margin.  A  surgeon  re- 
moved two  pieces  of  the  bullet  (supposedly  all  of  it),  together  with 
some  fragments  of  bone  at  the  wound  of  entrance,  which  finally 
healed.  The  patient  for  a  time  was  aphasic,  had  a  left-sided  hemi- 
plegia, and  he  subsequently  developed  epilepsy  with  a  peculiar 
speech  aura.  An  x-nxy  plate  then  showed  a  foreign  body  lodged  in 
the  left  side  of  the  brain  near  the  skull,  and  just  below  the  middle 
of  the  Sylvian  fissure.  An  operation  was  performed,  adhesions  due 
to  an  absorbed  subdural  clot  were  separated,  and  a  small,  dense  scar, 
inclosing  the  main  fragment  of  the  bullet,  was  removed.  This  had 
traversed  the  left  frontal  lobe,  had  struck  the  side  of  the  skull,  and 
ricocheted  into  its  position.  The  extraction  of  the  bullet  benefited 
him  in  no  respect,  and  he  is  progressing  to  mental  degeneracy. 

Treatment. — The  fracture  itself  is  the  least  of  the  ills  following 
cranial  gunshot  wounds  and  can  not  be  considered  apart  from  the 
other  complications.  If  there  is  a  clean-cut  perforation  and  no  serious 
immediate  symptoms  the  wound  may  be  left  with  a  simple  drain  and 
healing  may  take  place  without  incident;  for  luiless  septic  foreign 
particles  have  been  carried  in  with  the  missile,  its  track  quickly  cica- 
trizes and  the  bullet  itself  becomes  encapsulated.  If  there  is  a 
lacerated  scalp  and  considerable  local  comminution  of  the  skull  it  is 
advisable,  after  paring  the  edges  of  the  scalp  wound,  to  enlarge  it 
by  incision  and  to  trephine  the  skull  in  order  to  readjust  any  de- 
pressed fragments,  to  evacuate  clots,  to  relieve  tension,  and  to  aiforcl 
better  drainage.  A  large  defect  almost  always  leads  to  a  hernia  and 
perhaps  to  a  fungus  cerebri,  owing  to  the  swelling  of  the  lacerated 
brain.  Largely  owing  to  this,  drainage  of  the  track  of  the  bullet  is  a 
most  unsatisfactory  procedure,  and  one  must  usually  be  satisfied  with 
a  superficial  drain  down  to  the  dura  and  brain,  but  not  far  into 
the  latter.  The  temptation  to  probe  for,  to  locate,  and  to  extract 
deep-lying  fragments  of  the  bullet  should  be  resisted  by  the  surgeon ; 
for  even  if  successful  in  their  object  these  procedures  usually  serve 
merely  to  increase  the  damage  already  done  by  the  missile  without 
conferring  any  benefit  whatever  from  its  removal. 

The  late  complications  must  be  met  as  are  those  due  to  cranial 
injuries  from  other  causes,  and  here  again  it  must  be  borne  in  mind 
that  the  paralyses  and  mental  disturbances  are  not  due  to  the  presence 
13764—17 2 


18  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

of  the  foreign  body,  but  to  the  cicatricial  changes  in  the  nervous 
tissue  due  to  its  passage  through  them,  and  that  they  consequently 
are  the  same  whether  the  bullet  has  lodged,  emerged,  or  been 
removed. 

Fractures  according  to  their  situation — Fractures  of  the  vault  and 
fractures  of  the  base. — There  is  a  certain  justification  in  this  common 
anatomical  division,  for  in  the  two  situations  not  only  do  fractures 
differ  in  the  mechanism  of  their  production  but  also  in  the  form 
which  they  assume  and  in  the  complications  to  which  they  are  liable. 
The  bones  of  the  exposed  vault  are  more  liable  to  direct,  indenting 
injuries,  and  hence,  despite  their  greater  strength,  comminution  with 
dislocation  of  fragments  is  frequent;  those  of  the  well-protected, 
though  more  fragile  base,  are  more  subject  to  Assuring,  the  result  of 
general  deformation  of  the  skull.  These,  of  course,  are  not  invariable 
rules,  for  we  may  have  simple  fissures  of  the  vault  from  bursting  or 
a  local  comminution  with  depression  at  the  base  from  bending — an 
example  of  which  is  the  not  uncommon  fracture  which  occurs  about 
the  foramen  magnum  as  the  result  of  falls  on  the  buttock  when  a 
direct  blow  is  transmitted  to  the  base  through  the  spinal  column. 
Again,  a  simple  bending  fracture  of  the  base  may  follow  a  sharp 
blow  on  the  chin,  when  the  ramus  and  condyle  of  the  jaw  transmit 
the  force  to  the  base — the  prize-fighter's  fracture.  Finally,  it  is 
always  to  be  kept  in  mind  that  fractures  of  vault  and  of  base  are 
apt  to  be  associated. 

Many  statistical  studies  in  regard  to  cranial  fractures  have  been 
made  from  time  to  time ;  notable  among  them  is  the  recent  elaborate 
monograph  of  Hans  Brun,  based  on  470  cases  which  in  20  years 
had  been  carefully  observed  in  the  Cantonal  Hospital  in  Zurich. 

Occurrence. — In  general  it  may  be  said  that  they  are  injuries  oi 
young  adult  life ;  that  they  are  many  times  more  frequent  in  men  than 
in  women;  that  in  the  majority  of  cases  (60  per  cent)  they  are  the 
result  of  falls  from  a  height.  About  one-half  of  these  fractures  in- 
volve the  base,  often  alone,  sometimes  with  associated  fracturing  of 
the  vault.  On  the  other  hand,  it  is  estimated  that  TO  to  75  per  cent 
of  all  fractures  of  the  vault  are  accompanied  by  basal  injuries.  Frac- 
tures of  the  vault  are  more  often  compound  than  simple,  and  they 
occur  with  about  equal  frequency  in  frontal,  parietal,  and  temporal 
bones,  being  rare  in  the  occipital  region.  Basal  fractures  are  more 
common  in  the  midcranial  fossae. 

Mortality. — Disregarding  the  etiological  factor,  the  patient's  age. 
and  also  the  character  of  the  injury,  about  one-third  of  all  cases  in 
the  past  have  proved  fatal,  and  as  the  fatalities  are  largely  due  to  the 
immediate  cerebral  complications,  modern  methods  of  treatment  have 
not  served  to  greatly  alter  these  figures.  The  percentage  of  fatalities 
increases  with  age — the  younger  the  individual  the  more  favorable 


FKACTUEES   OF    THE    SKULL.  19 

the  outcome.  Fractures  of  the  base  are  coimiionl}'  thought  to  he 
attended  Avith  a  higher  mortality  than  those  of  the  vault,  though 
with  our  improved  diagnostic  measures  (lumbar  puncture,  for  ex- 
ample) we  may  find  that  many  cases  of  simple  basal  fracture  have 
heretofore  been  overlooked  and  regarded  merely  as  concussion — a 
fact  which  may  make  one's  percentage  of  recoveries  at  least  appear 
larger  to-da3^  Excluding  those  cases  which  have  died  as  an  iuunediate 
result  of  the  injury  and  those  which  have  later  succumbed  to  infec- 
tion, the  average  duration  of  life  in  the  fatal  cases  is  said  to  l)e 
44  hours;  so  that  there  is  some  basis  for  the  old  rule,  adhered  to  by 
Bergmann  and  Wagner,  that  survival  over  two  days  gives  a  favor- 
able prognosis. 

Of-  the  cases  which  survive  the  first  48  hours,  a  considerable  num- 
ber (S  per  cent  of  all  fatalities)  die  from  the  intermediate  complica- 
tions of  meningitis  or  abscess.  Fractures  of  the  base  are  more  liable 
to  this  complication  than  those  of  the  vault;  for  the  latter  are  ac- 
cessible and  easily  drained,  so  that,  unless  there  be  a  defect  leading 
to  a  fungus  cerebri,  dangerous  from  a  persisting  leak  of  cerebrospinal 
fluid,  infection  rarely  occurs.  Basal  fractures,  on  the  other  hand, 
especially  those  which  open  up  the  sphenoidal  or  ethmoidal  sinuses 
where  pathogenic  organisms  lurk,  are  often  followed  by  a  meningeal 
infection.  In  this  case  the  pneumococcus  is  the  more  common  agent, 
whereas  in  fractures  of  the  vault  a  streptococcal  or  staphylococcal 
infection  is  the  usual  one.  I  have  twice  seen  a  rapidly  fatal  pneumo- 
coccal meningitis  start  up  on  the  third  day  after  what  appeared  to  be 
a  simple,  uncomplicated  basal  fracture  with  a  little  bleeding  from  the 
nose  and  so  few  subjective  symptoms  that  the  patients  remonstrated 
at  their  enforced  recumbenc3^ 

The  prognosis  is  in  no  way  proportionate  to  the  extent  of  the 
cranial  injury,  but  depends  entirely  on  the  character  of  the  intra- 
cranial lesions  which  will  be  fully  considered  anon.  An  insignifi- 
cant crack  of  the  base,  associated"  with  a  focal  hemorrhage  in  pons 
or  medulla,  may  put  a  sudden  end  to  life;  whereas  an  extensive 
fragmentation  of  the  vault,  which  allows  for  considerable  cerebral 
expansion,  may  actually  save  life  through  "  decompression.-"'  An 
insignificant  punctured  fracture  which  does  not  even  produce  con- 
cussion may  prove  fatal  from  meningitis  or  abscess  later  ^  on ;  a 
conuninuted  and  depressed  compound  fracture  may,  on  the  one  hand, 
cause  death  quickly  from  hemorrhage  and  compression,  or  may 
heal  practically  untreated  and  give  few  symptoms.  On  the  whole 
the  immediate  prognosis  is  more  favorable  in  bending  fractures 
than  in  bursting  fractures;  in  other  words,  more  favorable  in  those 
which  are  accessible  than  in  those  which  are  not,  for  it  depends 
largely  on  the  possibility  of  early  treatment  not  only  of  the  frac- 
ture, but  of  its  underlying  complications. 


20  WAR    SUKGEBY    OF    THE    NEEVOUS    SYSTEM. 

The  diagnosis  of  fractures  of  the  vault  may  offer  clifHculties,  par- 
ticularly in  the  case  of  linear  fissures  and  of  those  involving  the 
inner  table  alone.  One,  however,  is  much  more  apt  to  be  misled  by 
the  jjeculiar  feel  of  the  infiltrated  edge  of  a  subaponeurotic  extra- 
vasation into  making  a  faulty  diagnosis  than  to  overlook  a  cranial 
fracture  when  it  is  actually  present.  When  the  scalp  is  intact, 
linear  fractures  may  at  times  be  recognized  through  lines  of  ten- 
derness on  pressure,  particularly  over  the  temporal  fossa,  and  by  a 
changed  percussion  note  if  there  is  any  gaping  of  the  fissure.  In 
open  wounds  there  should  be  no  difficulty  in  recognizing  even  a 
closel}^  approximated  fissure,  owing  to  the  blood  which  oozes  from 
between  its  edges;  sutures,  however,  may  be  mistaken  for  fissures. 
Localizing  cerebral  symptoms,  to  be  discussed  later,  are  often  help- 
ful in  determining  the  situation  of  a  depression  if  it  is  not  actually 
palpable,  and  involvement  of  cerebral  nerves  may  indicate  the  direc- 
tion taken  by  a  meridional  fissure.  Old  deformities  dating  from 
birth,  patches  of  senile  atrophy,  defects  from  former  diseases,  like 
syphilitic  osteomyelitis,  and  the  irregularities  present  in  all  skulls, 
though  more  marked  in  some,  may  at  times  be  mistaken  for 
depression. 

In  fractures  involving  the  base  alone  we  must,  in  the  long  run. 
depend  entirely  upon  the  symptoms  which  we  have  learned  to  recog- 
nize as  common  accompaniments  of  these  injuries,  rather  than  upon 
any  direct  evidence  of  the  bony  lesion.  Evidence  from  intracranial 
or  extracranial  bleeding,  either  free  or  into  the  tissues,  is  of  partic- 
ular value. 

The  intracranial  extravasations  usually  take  place  into  the  sub- 
dural space,  for,  owing  to  its  close  attachment,  the  dura  is  usually 
torn  when  the  bones  are  fissured.  The  amount  may  be  small  or  so 
extensive  as  to  cause  rapidly  fatal  compression.  It  ma^^  be  recog- 
nized by  finding  evenly  distributed  red  blood  corpuscles  in  the  cere- 
brospinal fluid  withdrawn  from  the  lumbar  meninges. 

The  extracranial  extravasations  may  also  be  free  and  bleeding  may 
occur  from  the  nose,  mouth,  or  ears,  in  case  the  ethmoid,  the  accessory 
sinuses,  the  Eustachian  tube,  or  the  tympanic  cavity  have  been  impli- 
cated. It  is  necessary  to  exclude  a  simple  "  bloody  nose,"  rupture  of 
the  tympanum,  or  entry  of  blood  from  Avithout  into  the  auditory 
canal.  Extravasations  into  the  tissues  (ecchymoses)  appear  more 
tardily.  They  are  common  in  the  orbit,  under  the  eyelids  or  con- 
junctiva when  the  frontal  plate  is  injured,  and  in  fractures  of  the 
middle  or  posterior  fossae  they  find  their  way  to  the  surface  over  the 
mastoid  process  or  down  the  neck  after  some  days. 

The  escape  of  cerebrospinal  fluid  often  occurs  with  fractures  enter- 
ing the  middle  fossa,  particularly  when  they  involve  the  petrous 
bone  and  when  both  dura  and  tympanum  have  been  torn.    The  escape 


FKACTUKES    OF    THE    SKULL.  ^  21 

of  bloody  fluid  may  continue  for  days  and  the  symptom  need  not 
always  be  entirely  undesii-able.  as  pressure  may  be  relieved  thereby. 
Open  fractures  which  conmiunicate  with  the  nasal  or  pharyngeal 
cavities  may  likewise  be  followed  by  a  leakage  of  cerebrospinal  fluid, 
though  it  is  less  common  from  these  situations.  In  rare  cases,  after 
a  lesion  of  the  petrous  bone  unaccompanied  by  rupture  of  the  tym- 
panic membrane,  fluid  may  escape  into  the  pharynx  by  way  of  the 
Eustachian  tube  and  either  be  swallowed  or  flow  from  one  nostril 
when  the  head  is  tilted  down. 

The  complications  of  cranial  fractures  often  ser\'e  as  an  aid  in 
diagnosis.  They  are  estimated  to  occur  in  46  per  cent  of  fractures  of 
the  vault  and  in  64  per  cent  of  those  of  the  base.  Varying  grades  of 
concussion,  contusion,  or  compression  are  almost  inevitable:  only 
exceptional  forms  of  fracture  occur  without  one  or  another  of  these 
classical  symptoms,  though  any  one  of  them  may  result  from  an 
injury  in  the  absence  of  fracture.  They  are  apt  to  be  more  outspoken 
in  basal  lesions,  owing  to  the  diffuse  character  of  the  blow  necessary 
to  produce  a  bursting  fracture.  As  will  be  described  in  its  proper 
section,  compression  may  be  general  or  local,  and  when  local  it  may 
give  cerebral  symptoms  of  irritation  or  of  paralysis,  which  serve  to 
point  out  the  situation  and  character  of  the  cranial  lesion.  This  is 
often  the  case  with  indented  fractures  of  the  vault  which  lead  to 
cortical  laceration  of  the  brain,  or  with  meridional  fissures  which 
cross  the  meningeal  groove  and  lead  to  extradural  hemorrhages  with 
their  characteristic  "  interval "  between  symptoms.  These  extradural 
hemorrhages  can  only  occur  under  the  vault  where  the  dura  is  more 
easily  separable  from  the  bone  than  at  the  base;  and  it  is  to  be  re- 
membered that  they  are  not  necessarily  an  indication  of  fracture,  but 
may  be  the  result  of  simple  deformation  not  sufficient  to  break  an 
elastic  skull. 

Involvement  of  the  cerebral  nerves  may  prove  a  valuable  diagnostic 
aid.  The  facial  is  by  far  the  most  commonly  injured,  owing  to  its 
devious  course  through  the  petrous  process,  so  frequently  implicated 
in  fissures  entering  the  middle  fossa.  The  mere  presence  of  hemi- 
tacial  palsy,  however,  after  an  injury  to  the  head  need  not  indicate 
with  certainty  the  peripheral  involvement  of  the  nerve,  for  it  may  be 
due  to  a  contralateral  central  lesion.  In  order  of  frequenc}''  the  ab- 
ducens  comes  after  the  facial,  and  diplopia  from  an  involvement  of 
any  or  all  of  the  oculomotor  nerves  may  be  the  result  of  breaks  in 
the  neighborhood  of  the  sphenoidal  fissure.  In  fissures  crossing  the 
frontal  fossa?  the  olfactory  often  suffers.  The  optic  may  be  affected 
i)y  direct  injury,  and  lesions  of  the  trigeminus,  glossojDharvngeal. 
v'agus,  spinal  accessory,  and  h^'jDOglossal  have  been  recorded.  The 
nerves  are  apt  to  be  affected  in  gi'oups,  the  se\'enth,  eighth,  and  sixtii 
together;  the  fifth  and  third;  or  the  ninth,  tenth,  and  eleventh.      The 


22  WAR    SURGERY    OF    THE    KERVOUS    SYSTEM. 

le.-ions  usuall}-  occur  at  or  near  their  foramina  of  exit,  cine  cither  to 
actual  laceration  or  to  local  compression  from  effused  blood;  and 
hence  a  stud}'  of  the  paralyses  may  indicate  the  fossa  which  the  f rac- 
tnre  has  entered,  Avhether  anterior,  middle,  or  posterior. 

iSerious  complications  from  hemorrhage  maj^  follow  injuries  to 
Mood  vessels,  particularly  Avhen  the  sinuses  or  meningeal  artery  are 
lacerated,  and  occasionally  linear  fractures  crossing  the  middle  fossa 
toAvard  the  pituitary  fossa  may  so  traumatize  the  cavernous  sinus 
and  carotid  as  to  produce  an  arteriovenous  aneurysm  with  pulsating 
exophthalmos. 

The  sequels  heretofore  considered  are  common  to  all  lesions  of  the 
skull;  those  due  to  an  infection  are  almost  without  exception  limited 
to  open  fractures,  whether  of  base  or  vault.  In  them  purulent  cellu- 
litis, osteomyelitis,  septic  sinus  thrombosis,  meningitis,  or  cerebral 
abscess  were  formerh'  almost  to  be  expected.  Modern  methods  have 
largely  Jessened  these  evils  in  the  case  of  the  vault,  even  if  not  in  basal 
lesions. 

An  insignificant  fissure  which  passes  across  the  ethmoid  plate  may 
open  a  pathwav  of  infection  from  the  nasal  cavity  and  lead  to  a 
rapidly  fatal  meningitis.  Cerebral  abscess  is  especially  common 
after  ]5unctured  or  gunshot  wounds  from  the  deep  inoculation  of  in- 
fective agents,  though  it  occurs  often  enough  in  compound  commi- 
nuted fractures  which  have  led  merely  to  a  superficial  laceration  of 
rhe  cortex. 

Barer  complications,  like  spurious  meningocele,  pneumatocele,  and 
others  too  numerous  to  mention,  may  llkevN'ise  occur.  Cysts  occasion- 
ally form  after  fractures  either  from  a  torn  dura,  from  the  parti;il 
absorption  of  a  clot  in  the  subdural  space,  or  from  a  subcortical 
extravasation.  vSugar  may  appear  in  the  urine  (traumatic  glycosu- 
ria), usually  about  8  to  12  hours  after  the  injury  and  in  about  f)  per 
cent  of  all  cases,  according  to  Higgins  and  Ogden.  All  of  these,  as 
well  as  the  so-called  post-traumatic  neuroses,  result  from  the  cerebral, 
not  from  the  cranial  injury. 

The  ■process  of  healing  does  not  take  place  as  in  the  long  bones, 
where  there  is  an  abundant  callus  formation.  Dura  and  periosteum, 
however,  are  both  capable  of  forming  neAv  bone,  as  we  have  seen  in 
ex'^stoses,  osteophytes,  etc.,  and  complete  repair,  even  when  there  has 
been  a  loss  of  substance,  may  occur.  It  may,  however,  l^e  long  de- 
layed or  completely  fail,  due,  according  to  Bergmann,  to  the  de- 
struction or  less  of  the  osteoplastic  layer  of  both  inner  and  outer 
periosteum  as  well  as  to  the  absence  of  movement  which  ordinarily 
stimulates  callus  formation. 

Union  often  occurs  by  fibrous  membrane  alone;  even  narrow  fis- 
sures may  fail  to  become  reunited  b}-  bone.  As  a  rule,  however,  a 
slow  process  of  bone  production  and  bone  absorption  goes  on,  hand  in 


FEAOTURES   OF   THE   SKITLI,.  23 

hand,  and  irregular  edges  or  depressed  fragments  are  rounded  off 
as  the  gaps  are  more  or  less  filled  in.  Occasionally  there  is  an  over- 
production of  new  bone,  leading  to  focal  or  to  widespread  hyperos- 
toses from  either  the  outer  or  inner  table.  Even  defects  of  some  size 
may  at  times  become  entirely  ossified,  and  even  when  closed  by  mem- 
brane alone  they  may  become  so  firm  and  inelastic  as  to  show  no  pul- 
sation. According  to  Bergmann,  defects  can  not  be  expected  to  close 
if  the}^  exceed  a  diameter  of  (5  to  8  centimeters,  and  it  would  indeed 
seems  that  it  is  rare  even  for  much  smaller  openings  to  fill  in. 

There  is  a  great  difference  of  opinion  as  to  the  injnrious  effect  of 
these  bone  defects,  some  holding  the  view  that  when  extensive  they 
lead,  in  the  course  of  time,  to  serious  mental  symptoms.  Personally 
1  do  not  believe  that  they  are  injurious  unless  accompanied  by  an 
underlying  lesion  of  the  dura.  When  the  dura  is  wounded  and  the 
scar  formation  leads  to  adhesions  between  overlying  scalp  and  brain, 
the  chronic  fibrous  changes  which  result  may  lead  in  time  to  ex- 
tensive cortical  alterations  and  mental  deterioration.  With  an  in- 
tact dura,  however,  such  symptoms  are  less  likely  to  occur. 

Treatmient. — We  are  confronted  again  by  the  necessity  of  distin- 
guishing between  the  management  of  the  fracture  itself  and  the  man- 
agement of  its  complications.  Relatively,  simple  rules  can  be  laid 
down  for  the  former ;  for  the  latter  our  conduct  is  largely  controlled 
b_y  physiological  laws  relating  to  the  circulation  of  the  blood  and  cere- 
brospinal fluid  under  abnormal  conditions.  In  fractures  of  the  vault 
the  indication  for  surgical  intervention  is  usually  deformation  of 
fragments,  rather  than  critical  cerebral  complications;  in  fractures 
of  the  base  it  is  the  reverse,  for  there  intracranial  complications  are 
especially  serious  and  deformation  is  rare. 

In  compound  injuries  of  the  vault  we  may  easily  determine  the  form 
and  estimate  the  consequences  of  the  injurj^,  and  our  endeavor  should 
be  to  thoroughly  cleanse  the  wound,  to  elevate  depressed  fragments, 
to  restore  a  wound  in  the  dura  if  one  exists,  and  to  leave  the  parts  as 
nearly  in  their  natural  position  as  possible.  If  the  fragments  are 
depressed  and  wedged  it  may  be  necessary  to  trephine  at  the  edge  of 
the  depression  before  they  can  be  pried  into  place.  Even  in  the  ab- 
sence of  visible  depression  an  opening  may  be  required  when  cerebral 
symptoms  are  present,  due  to  depression  from  the  inner  table  alone  or 
to  intracranial  hemorrhage. 

It  is  another  matter  when  injuries  of  the  vault  are  covered  by 
intact  scalp,  for  there  maj^  often  be  great  difficulty  in  determining 
whether  there  is  sufficient  justification  to  transform  a  simple  into  a 
compound  fracture,  even  for  the  sake  of  determining  the  lesion.  It 
is  largely  a  personal  matter  and  rests  with  the  judgment  of  the  oper- 
ator; and  this  in  turn  depends  entirely  upon  his  familiarity  with 
intracranial  disturbances  which  are  amenable  to  operative  treatment 


24  WAR   SURGERY   OP   THE    NERVOUS   SYSTEM. 

and  his  ability  to  safely  cope  with  them  when  found.  A  simple 
fissure,  which  crosses  the  temporal  region,  of  itself  needs  no  surgical 
interA^ention,  but  this  is  urgently  called  for  when  pressure  symptoms 
indicate  either  a  lesion  of  the  meningeal  or  free  extravasation  at  the 
base.  When  simple  fractures  are  accompanied  by  evident  depression 
surgical  measures  are  indicated,  even  in  the  absence  of  immediate 
cerebral  symptoms,  for  unelevated  fragments  are  almost  certain  to 
be  the  source  of  future  trouble,  especially  if  the  dura  has  been  in- 
jured. The  opening  must  be  carefully  examined  on  all  sides,  for  de- 
pressed fragments  are  readily  overlooked.  In  Fig.  50  is  shown  a  pa- 
tient with  a  depressed  fracture  which  had  solidly  healed,  in  so  far  as 
the  union  of  the  displaced  fragments  was  concerned,  and  the  rounding' 
off  of  their  sharp  edges,  and  yet  serious  mental  (left  frontal  lobe) 
symptoms  resulted.  In  an  old  healed  depression  of  this  sort  it  is 
necessary  to  remove  the  entire  area  by  a  circular  incision  and  either 
to  leave  a  defect,  to  replace  it  by  some  foreign  material,  or  to  cover  it 
by  an  osteoplastic  flap.  Occasionally  the  cup-shaped  area  may  be 
replaced  inverted  without  subsequent  necrosis. 

When  there  is  extensive  comminution  with  many  lose  fragments 
it  may  be  difficult  to  determine  whether  any  of  them  should  be  re- 
moved, owing  to  possible  loss  of  viability.  The  dread  of  necrosis 
and  of  infection,  though  a  natural  one,  is  largely  an  inheritance  from 
our  surgical  forefathers,  and  it  is  a  matter  of  present-day  experience 
to  find  that  fragments  of  surprising  size,  even  when  completely  sep- 
arated, will  survive  if  left  in  a  clean  wound.  It  formerly  was  the 
custom  to  remove  all  completely  detached  pieces.  It  has  been  learned, 
however,  that  even  boiled  fragments  may  heal  after  reinsertion. 
I  have  quite  frequently  rejjlaced  a  3-cm.  trephine  button  after  boiling 
it  (owing  to  some  suspicion  of  its  perfect  cleanliness),  and  have 
never  seen  it  fail  to  heal  in  place ;  it  is  well  known,  of  course,  that  an 
unboiled  fragment  of  this  size  can  always  be  safely  replaced.  In  the 
latter  case  it  is  probable  that  bone-forming  cells  of  either  surface 
or  of  the  diploe  may  remain  viable,  but  in  the  former  instance  they 
have  been  destroyed  and  it  is  to  be  presumed  that  the  fragment  acts 
only  as  a  temporary  stimulus  for  new^  tissue,  becoming  itself  ulti- 
mately absorbed.  The  queston  of  closure  of  defects  will  be  consid- 
ered later. 

The  treatment  of  basal  fractures  resolves  itself  largely  into  the 
treatment  of  contusion  or  compression  of  varying  degrees,  for  which 
our  therapy  is  largely  restricted  to  rest,  absolute  quiet,  an  ice  cap,, 
sedatives  when  headache  is  severe  or  when  there  is  great  restlessn^'ss, 
and  to  free  evacuation  of  the  bowels,  preferably  with  a  saline — 
measures  to  be  observed  in  practically  all  cases  of  cranial  injury.  The 
greatest  care  should  always  be  exercised  in  handling  and  in  trans- 


FRACTURES    OF    THE    SKULL.  25 

porting  any  case  of  fractiu-e  witli  intrat^ranial   syniptoiiis.  for  the 
symptoms  are  much  aggravated  by  any  form  of  jolting. 

With  the  view  of  preventing  infection  in  case  there  is  bleeding  or 
loss  of  cerebro.^pinal  fluid  from  the  nose  or  ears,  it  is  customary  to 
irrigate  and  tamponade  the  auditory  meatus  or  the  nasal  chamber. 
This  procedure,  however,  can  be  overdone,  and  only  in  case  the  hem- 
orrhage is  profuse  is  it  justifiable  to  actually  pack  these  orifices,  for 
nothing  is  more  certain  to  set  up  a  suppurative  infection  of  the 
mucous  membrane.  Irrigation  of  the  nose  or  of  the  ear  to  remove 
clotted  blood  and  to  cleanse  the  cavities  has  an  element  of  danger, 
and  it  is  preferable  to  accomplish  this  by  merely  wiping  out  the 
passages  with  a  sterile  cotton  swab  moistened  in  a  mild  antiseptic 
solution.  It  is  important  not  to  irrigate  the  kSchneiderian  mem- 
brane in  such  a  way  as  to  produce  a  sneeze,  for  on  more  than  one 
occasion  this  has  been  disastrous  and  the  explosive  effect  has  driven 
septic  material  into  the  middle  ear  or  ethmoidal  cells  and  appar- 
ently has  been  the  active  agent  in  inaugurating  a  septic  meningitis, 
After  cleansing,  the  cavities  should  be  loosely  closed  by  a  wisp  of 
absorbent  cotton,  or  of  iodoform  gauze  if  desired,  which  will  serve 
to  take  up  the  secretions  and  which  should  be  frequently  changed  if 
there  is  abundant  discharge.  Although  by  energetic  measures  we  rasLj 
overcome  a  local  meningeal  infection  which  has  started  over  the 
hemisphere,  we  stand  practically  helpless  before  one  originating  at 
the  base,  although  suboccipital  drainage  in  a  few  cases  has  apparently 
resulted  in  cure. 

One  can  speak  somewhat  more  encouragingly  in  regard  to  active 
interference  in  case  of  diffuse  hemorrhage.  The  fatalities  from  this 
cause,  as  will  be  detailed  in  the  section  dealing  with  compression, 
are  due  to  a  final  implication  of  the  vital  centers  in  the  medulla  when 
the  amount  of  effused  blood  is  sufficient  to  so  increase  intracranial 
tension  that  they  are  thrown  out  of  function  from  anemia.  Though 
this  has  been  Avell  recognized,  operative  methods  of  meeting  the 
situation  have  been  inefficient  or  untried,  owing  to  the  feeling  of 
hopelessness  in  the  presence  of  continual  oozing  from  an  inaccessible 
and  often  uncertain  lesion.  Exploratorj^  openings  have  usually  been 
made  over  the  vault,  but,  owing  to  the  increased  cerebral  tension, 
such  openings  become  filled  with  a  bulging  brain,  drainage  can  not 
be  effective,  and  a  fungus  cerebri  is  often  produced. 

It  is  self-evident  that  an  opening  as  near  the  lesion  as  possible 
is  desirable,  and,  inasmuch  as  most  of  these  fractures  enter  the 
middle  fossa,  an  opening  low  down  in  the  temporal  region  is  most 
likely  to  be  efficacious.  The  author's  procedure,  which  has  been 
designated  as  an  intermusculotemporal  operation,  often  meets  the 
needs  of  the  condition.    In  this  o]Deration,  by  splitting  the  temporal 


26  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

muscle  in  line  of  its  fibers  and  by  rongeuring  away  the  thin  squamous 
wing  of  temporal  and  adjoining  sphenoid,  not  only  is  the  region  over- 
lying the  meningeal  vessels  exposed,  so  that  a  chance  extradural  hem- 
orrhage can  be  brought  to  light,  but  also  the  dura  over  the  temporal 
lobes  is  exposed  and  the  presence  or  absence  of  subdural  effusion  can 
be  determined.  The  dura  should  be  opened  and  there  will  usually  be 
an  abundant  escape  of  bloody  cerebrospinal  fluid,  Avhose  evacuation 
will  be  aided  by  passing  a  curved,  blunt  dissector  down  under  the 
temporal  lobe.  Oftentimes  edema,  as  we  have  seen,  has  played  the 
chief  role  in  the  compression,  and  we  may  find  that  merelj^  a  so-called 
"  serous  meningitis  "  is  present,  and  that  evacuation  of  a  large  amount 
of  fluid  will  diminish  the  tension.  In  such  case  the  muscle  and  scalp 
may  be  closed,  but  if  there  is  continuous  bleeding  it  is  well  to  close 
the  muscle  only  in  part  and  to  leave,  at  its  lower  angle,  a  strip  of 
rubber  protective,  leading  under  the  temporal  lobe  as  a  drain.  In 
case  the  craniectomy  on  one  side  alone  seems  insufficient  a  bilateral 
operation  may  be  performed  at  the  same  or  at  a  subsequent  sitting, 
for  the  procedure  is  simple  and  not  attended  by  shock.  Its  advan- 
tages are  due  to  (1)  the  frequency  of  the  bony  lesion  in  the  middle 
fossa;  (2)  the  fact  that  cerebral  contusions  are  especially  liable  to 
involve  the  tip  of  the  temporal  lobe;  (3)  the  exposure  of  the  menin- 
geal territory  and  ease  of  determining  the  presence  of  an  extradural 
hemorrhage;  (4)  the  possibility  of  draining  through  a  split  muscle 
rather  than  directly  through  the  scalp;  and  (5)  the  subsequent  pro- 
tective action  of  the  muscle  in  case  a  hernia  tends  to  form  in  conse- 
quence of  traumatic  edema.  The  unilateral  or  bilateral  defect  in 
this  situation  leads  to  no  complications  and  no  subsequent  deformity. 


Part  2. 

MENINGES,  EPENDYMA,  AND  BRAIN. 

MENINGES  AND  EPENDYMA. 

Anatomic  and  physiologic  considerations — The  pachymeninx  and  its 

vessels. — A  thorough  knowledge  of  these  membranes  and  the  part 
played  in  intracranial  disease  by  the  fluids  which  they  hold  is  of 
pi-ime  importance.  It  is  permissible  to  call  attention  liere  to  some  ot 
the  more  essential  points  only. 

The  dura  carries  on  its  outer  surface  certain  arteries  of  surgical 
interest  and  it  incloses  the  great  venous  sinuses.  The  intracranial 
dura  differs  from  the  intraspinal  dura  in  its  relation  to  the  inclosing 
bone;  for  the  latter  has  a  double,  the  former  only  a  single  inner  layer 
of  endothelial  cells,  its  outer  surface  adhering  more  or  less  firmly  to 
the  skull  and  having,  especially  in  the  young,  an  active  share  in  the 
process  of  bone  formation.  This  attachment  is  an  intimate  one,  par- 
ticularly at  the  base,  from  portions  of  which  the  dura  can  be  separated 
only  with  great  difficulty.  Hence  in  linear  fractures  of  the  base  the 
membrane  is  almost  always  torn:  in  similar  fractures  of  the  vault 
it  may  often  escape  injury.  One  source  of  its  firm  adherence  is  to 
be  found  in  the  sheath-like  prolongation  of  the  membrane  along 
the  course  of  the  cerebral  nerves.  Such  a  sheath  is  especially  marked 
in  the  case  of  the  optic  nerve — a  fact  of  importance  in  the  etiology  of 
choked  disk.  OAving  to  this  firm  basal  attachment  extradural  hem- 
orrhages are  less  likely  to  occur  there  than  under  the  vault;  this  is 
not  an  invariable  rule,  for  in  certain  parts  of  the  middle  and  posterior 
fossfe  it  is  readily  separable  from  the  bone — a  fact  which  is  made  use 
of  in  exposing  the  trigeminal  nerve  and  in  suboccipital  operations. 
Tlie  strength  of  the  clural  attachment  at  the  vault  is  variable ;  it  in- 
creases with  age,  so  that  the  membrane  tears  in  removal;  in  the  young- 
it  clings  much  more  firmly  to  the  growing  bone  at  the  sutures  than 
elsewhere.  In  the  newborn,  for  this  reason,  an  extradural  hem- 
orrhage {^''internal  cephalhematoma")  may  be  limited  to  the  inner 
surface  of  one  bone. 

As  a  protection  for  the  brain,  the  clura,  owing  to  its  smooth  endo- 
thelial surface,  is  of  much  more  importance  than  the  overlying  bone. 
A  dural  defect  is  replaced  by  scar  tissue,  which  of  necessity  leads  to 
adhesions  between  the  cortical  leptomeninges  and  overlying  cranium 

27 


28  WAR   SURGEEY    OF    THE    1\"ER.V0US    SYSTEM. 

or  scalp,  as  the  case  luaj'^  be ;  a  clural  wound,  the  edges  of  which  have 
been  accuratel}^  approximated,  shoukl  leave  no  such  adhesions,  as  the 
edge  is  quickly  united  by  proliferation  of  the  endothelial  cells.  The 
dura  is,  in  a  measure,  separable  by  dissection  into  two  layers — an 
outer  and  inner — between  which  structures  like  the  Gasserian  gang- 
lion are  inclosed;  it  furthermore  opens  to  inclose  the  large  sinuses, 
from  the  inner  edge  of  which  falx  and  tentorium  pass  off  to  parti- 
tion the  cranial  space  into  its  three  main  chambers.  These  strong 
membranous  partitions  play  an  important  part  in  supporting  the 
hemispheres,  and,  inasmuch  as  they  can  be  dislocated  but  slightly 
out  of  their  normal  position,  they  have  a  tendency  to  limit  the  pres- 
sure effects  of  a  local  process  to  the  one  compartment  in  which  it 
has  originated.  This  is  especially  so  with  the  subtentorial  compart- 
ment, for  the  tent  like  membrane  hung  from  the  posterior  edge  of 
the  falx  is  particularly  well  adapted  to  support  pressure  from  above 
and  thus  protect  the  important  centers  of  pons  and  medulla. 

The  dura  deserves  chief  consideration  as  a  carrier  of  blood  vessels. 
The  superior  longitudinal  s^inus  lies  slightly  to  the  right  of  the  me- 
dian line.  It  increases  in  its  blood-holding  capacity  as  it  runs  from 
the  ethmoid  to  the  torcular.  In  its  course  it  changes  greatly  in  form. 
On  cross-section,  except  during  its  middle  course,  it  is  of  a  narrow, 
Avedge  shape,  the  apex  of  the  wedge  running  down  for  a  considerable 
distance  between  the  two  layers  of  the  falx.  During  its  middle 
sourse  broad  expansions  {lacuna}  laterales  or  parasinoidal  sinuses) 
pass  out  between  the  two  clural  layers  for  a  distance  of  from  1.5  to 
2.5  cm.  over  the  hemisphere.  Into  these  lateral  expansions  enter 
many  of  the  more  important  of  the  superior  cerebral  veins,  particu- 
larly those  which  ascend  in  the  sulci  bounding  the  paracentral  convo- 
lutions, and  from  them  emissary  vessels  pass  through  the  inner  table 
to  communicate  with  the  diploetic  vessels. 

Into  the  lacuna,  laterales  project  the  majority  of  those  bodies 
known  as  Pacchionian  granulations.  They  seem  to  be  an  acquire- 
ment of  adult  life  and  their  function,  if  they  possess  any,  is  uncer- 
tain. They  consist  of  tuftlike  processes  from  the  arachnoid  con- 
taining cerebrospinal  fluid;  and,  covered  merely  by  a  thinned-out 
layer  of  clural  endothelium,  the}^  project  into  and  are  bathed  in  the 
blood  of  the  sinus.  As  they  enlarge  they  may  even  project  through 
the  lateral  expansion  of  the  sinus  and  cause,  through  pressure, 
atrophic  depressions  of  varying  size  in  the  under  surface  of  the 
skull.  It  is  for  these  reasons  that  injuries  to  the  skull  in  this  situa- 
tion or  efforts  to  operate  there  are  especially  likely  to  be  attended 
by  hemorrhage;  for  the  calvarium  cannot  be  separated  from  the 
dura  without  tearing  the  emissary  veins  or  injuring  the  thinned-out 
layers  of  the  dura  covering  the  granulations.  Furthermore,  the  dura 
itself  can  not  be  elevated  from  the  brain  without  injury  to  the  cerebral 


MENINfiKS,    KPEISIDYMA,    AND    I3HAIN.  29 

veins,  whicli,  as  well  as  the  Piicchioniaii  gTaniilatioiis,  serve  to  bind  it, 
to  the  c;ortex.  Since  the  lacunie  laterales  are  sufficiently  broad  to 
cover  the  motor  centers  for  the  lower  extremities,  it  is  evident  that 
these  centers  are  difficult  of  access.  Owing  to  the  lacunie  also,  liga- 
tion of  this  sinus  in  its  middle  course  is  almost  impossible.  The  longi- 
tudinal sinus  and  its  expansions,  furthermore,  are  honeycombed  by 
fibrous  bands  {chor<hp  Willisii).  which  pass  in  various  directions  and 
many  of  Avhich  seem  to  serve  as  valves  at  the  point  of  entry  for  the 
superior  cerebral  veins.  These  vessels  enter  the  sinus  by  long, 
obliquely  placed  channels  which  pass  forward  against  the  direction 
of  the  blood  current. 

At  the  torcular  the  longitudinal  sinus  bifurcates  into  the  lateral 
sinuses,  the  right  being  usually  tlie  lai'ger.  These  sinuses  lie  in  the 
tri-angular  space  at  the  tentorial  attachment  and.  usually  with  a  slight 
upward  convexity,  pass  to  the  mastoid  region  of  the  skull,  where, 
as  Ihe  si</m()}fl  sinus,  with  a  sharp  curve  they  turn  downward  to 
become  the  internal  jugular  vein  at  the  foramen  of  the  same  name. 
At  the  posterior  part  of  the  mastoid  process  there  is  a  foramen  foi" 
a  large  emissary  vessel  which  forms  a  communication  between  veins 
of  the  scalp  and  the  lateral  sinus.  Injury  of  these  communicating- 
veins  in  attempting  to  i-emove  the  overlying  bone  for  operative  pur- 
poses may  lead,  especially  when  there  is  any  venous  stasis,  to  profuse 
hemorrhage,  for  such  an  accident  amounts  to  a  lateral  injury  to  the 
sinus  itself.  Communicating  vessels  also  pass  from  the  sinus  to  the 
bone  at  the  occipital  protuberance  opposite  the  torcular.  and  here 
again  especial  care  must  be  exercised  in  removal  of  bone.  During 
the  middle  course  of  the  lateral  sinuses  there  are  no  important 
vascular  ccmimunications,  and  in  operations  the  bone  may  be  ron- 
.  geured  away  from  the  dura  without  risk  of  bleeding.  Owing  to  the 
particularly  close  attachment  of  the  dura  to  the  petrous  bone  the 
petrosal  sinuses  are  important,  as  they  are  apt  to  be  injured  in  the 
linear  fractures  which  so  commonly  invade  this  fragile  part  of  the 
base.  The  hemorrhage  therefrom  either  directly  enters  the  subdural 
space  or  appears  from  the  external  meatus. 

A  sagittally  placed  occipital  sinus  connecting  torcular  with  the 
venous  sinuses  of  the  spinal  canal  lies  at  the  junction  of  the  dura  of 
the  posterior  fossa  and  the  cerebellar  falx.  Unlike  the  falx  cerebri 
this  membranous  expansion  is  of  variable  size  and  not  infrequently 
both  it  and  its  marginal  vessel  are  small  or  absent.  It  is  my  impres- 
sion that  when  the  sinus  is  absent  its  place  is  taken  by  large  median 
diploetic  vessels  which  run  in  the  midoccipital  ridge  to  the  edge  of 
the  foramen  magnum  and  thence  to  the  condylar  foramina.  Dip- 
loetic vessels  here  may  prove  troublesome  in  the  suboccipital  ap- 
proach to  cerebellar  operations. 


30  WAR   SUEGERY   OF   THE    NERVOUS   SYSTEM. 

Furthermore,  at  the  base  lies  another  important  sinus — the 
caveryiovs.  As  it  lies  alongside  of  the  sella  turcica  it  may  be  injured 
by  bursting  fractures  whose  fissures  so  often  enter  this  region,  and 
its  companion  vessel,  the  internal  carotid  artery,  may  be  harmed  at 
the  same  time,  leading  to  an  arteriovenous  aneurysm.  As  it  drains 
the  venous  blood  from  the  brow  and  orbit  it  is  liable  to  infection 
spreading  from  these  vessels;  and  when  compressed,  as  by  tumor,  the 
resulting  venous  stasis  in  the  bulbar  circulation  is  supposed  by  some 
to  be  the  causal  factor  in  producing  a  choked  disk.  When  throm- 
bosed it  produces  an  extraordinary  degree  of  exophthalmos,  usually 
resulting  in  blindness. 

There  has  been  much  discussion  among  experimentalists  concern- 
ing the  compressibility  of  the  sinuses,  and  from  their  peculiar  foi*m 
.and  protected  situation  thej'^  have  been  regarded  as  incompressible.  I 
succeeded  in  demonstrating  that  in  the  dog  the  longitudinal  sinus 
may  completely  collapse  at  an  early  stage  of  compression,  with  conse- 
quent venous  stasis  of  high  degree.  If,  with  increased  tension  from 
an}''  source,  a  similar  collapse  may  be  produced  in  the  slivus  rectus. 
with  stasis  in  the  venae  Galena?,  an  internal  hydrocephalus  may  be 
produced  without  the  direct  implication  of  these  vessels  by  pressure 
from  a  neighboring  growth. 

The  middle  meningeal  artery  serves  as  the  chief  arterial  supply  for 
the  dura.  Its  intimate  connection  with  the  membrane  is  such  that  in 
separating  dura  from  skull  it  clings  to  the  former,  though  there  are 
often  small  branches  which  enter  the  bone.  However,  at  one  place — 
the  anterior  inferior  angle  of  the  parietal,  near  the  pterion — it 
grooves  or  actually  may  channel  the  bone,  so  that  separation  is  often 
impossible  without  troublesome  hemorrhage.  Linear  fractures  cross- 
ing the  pterion  are  also  almost  certain  to  injure  the  vessel. 

The  nerve  supply  of  the  dura  is  abundant.  Unlike  the  leptomen- 
inges,  it  contains  sensory  and  vasomotor  nerves,  the  chief  supply  com- 
ing from  the  trigeminus,  although  about  the  foramen  magnum  there 
are  fibers  from  the  vagus.  Headaches  I  believe  to  be  due  to  the 
stretching  of  the  dura  or  of  its  expansions. 

The  leptomeninges,  ependyma,  and  cerebrospinal  fluid. — The  pia^  a 
delicate  and  vascular  membrane,  closely  hugs  the  convoluted  surface 
of  the  central  nervous  system;  fitting  like  a  glove  it  dips  down  into 
all  of  the  fissures  and  irregularities.  The  arachnoid^  on  the  other 
hand,  bridges  over  most  of  the  crevices,  and  in  its  relation  to  the  pia 
ma}^  be  likened  to  a  mitten  drawn  over  the  pial  glove.  On  the  top  of 
the  convolution  where  these  membranes  come  in  contact  they  are  in- 
tricately associated ;  over  the  sulci  and  fissures,  and  particularly  over 
the  irregularities  of  the  base,  they  ai'e  more  or  less  widely  separated. 
Unlike  the  free  subdural  space,  these  subarachnoid  spaces  are  honey- 


MENINGES,   EPENDYMA,    AND   BRAIN.  '  31 

combed  by  delicate  tissue  strands  which  bind  pia  and  arachnoid 
loosely  together.  This  loose  tissue  meshwork  is  traversed  by  many 
of  the  cortical  vessels  Avhose  tissue  support  consequently  is  slight. 
The  cerebrospinal  fluid  circulates  in  these  spaces. 

The  epenclyma^  which  lines  the  ventricular  cavities,  consists  of  a 
layer  of  epithelial  cells,  underlain,  for  the  most  i)art,  by  a  thin  layer 
of  neuroglia.  It  forms  a  covering  for  the  velum  interpositum  and 
the  vascular  choroid  plexuses  Avhich  curve  backward  through  the 
foramina  of  Monro  and  project  into  the  posterior  cornua  of  the  ven- 
tricles. Though  morphologists  have  shown  us  how  these  important 
structures  develop,  their  physiological  signification  remains  obscure. 
and  consequently  their  diseases  even  more  so.  They  doubtless  play 
the  chief  role  in  the  formation  of  cerebrospinal  fluid,  and  it  is  es- 
sential that  we  have,  as  a  working  basis,  some  knowledge  of  the  func- 
tion of  this  fluid. 

The  cerebrospinal  fluid  is  not,  as  was  long  conjectured,  merely 
a  surface  lubricant  akin  to  the  fluid  of  the  great  serous  cavities;  nor 
does  it  act  alone  as  a  Avater-bed,  though  the  comparatively  large  col- 
lections of  fluid  in  the  subtentorial  cisterns  serve  in  a  measure  as  a 
support  for  the  important  centers  of  the  hind-brain  and  lessen  the 
jar  which  they  Avould  otherwise  receive  in  case  of  a  cranial  injur3^ 
Leonard  Hill  expressed  the  opinion  that  the  cerebrospinal  fluid  should 
be  regarded  as  the  lymph  of  the  brain,  but,  as  Halliburton  has 
shown,  it  is  a  true  secretion  and  not  an  exudation  like  lymph,  from 
which  it  has  marked  chemical  diiferences.  The  subarachnoid  space 
is  only  remotely  connected  with  the  lymphatic  system,  being  fullj^ 
developed  long  before  the  lymphatics  have  budded  out  from  the  sub- 
clavian and  iliac  veins  (Sabin).  Observations  undertaken  for  me  by 
Lewis  Reford  in  Mall's  laboratory  show  that  the  spinal  arachnoid  is 
completed  first,  and  in  later  weeks  spreads  slowly  over  the  hemis- 
pheres. Reford 's  observations,  furthermore,  have  shoAvn  that  from 
the  beginning  the  spinal  subarachnoid  space  is  intimately  connected 
with  the  venous  circulation  through  the  rudimentary  cerebral 
sinuses. 

There  appears  to  be  an  active  secretion  and  circulation  of  this 
fluid,  which,  under  certain  circumstances  at  least,  may  form  in  large 
amounts.  This  is  shown  not  only  by  the  copious  discharge  after 
certain  cases  of  cranial  or  spinal  injury  or  in  nasal  rhinorrhea,  but 
also  by  the  rapid  reaccumulation  of  fluid  in  a  hydrocephalic  head 
after  its  withdrawal. 

Of  the  manner  in  which  this  fluid  gathers  we  are  as  yet  unaware. 
It  may  be  entirely  a  transudation  from  the  capillaries  of  the  vascular 
choroid — a  view  held  by  Leonard  Hill — or,  what  seems  to  me  more 
probable,  it  may  be  largely  the  product  of  secretory  activity  of  the 


32  WAR    SURGEEY    OF    THE    NEEVOUS    SYSTEM. 

ependymal  cells  which  line  the  choroid  plexus,  the  function  of  which  ^ 
has  not  been  definite!}-  established.  However  this  may  be,  the  fluid 
originates  in  the  lateral  ventricles,  whence,  passing  backward  by  the 
median  ventricle  to  the  hind-brain,  it  escapes  into  the  subarachnoid 
space  by  way  of  the  so-called  foramina  of  Magenclie  and  of  Luschka. 
From  this  point  the  fluid  bathes  both  the  cord  and  brain.  It  is 
chiefly,  though  not  entirely,  confined  to  the  ventricular  and  suba- 
rachnoid spaces.  Outside  of  the  arachnoid  there  normally  exists 
little  free  fluid,  though  it  may  gradually  make  its  way  through  this 
membrane.  When  exposed  in  an  operation  the  arachnoid  may  be 
seen  to  exude  drops  of  fluid — to  sweat,  as  it  were — but  not  until  it 
has  been  pricked  in  the  intergyral  spaces  Avill  sufficient  fluid  escape 
to  alloM^  the  membrane  to  settle  down  closely  over  the  pia — a  matter 
of  importance  in  cortical  faradization  to  be  emphasized  later. 

Once  it  has  emerged  from  the  ventricle  and  reached  the  surface  of 
the  brain,  the  fluid  may  leave  the  cranial  and  spinal  chambers  by 
forcing  its  wa}^  into  the  Ij^mph  spaces  along  the  course  of  the  nerves, 
and  in  this  way  may  pass  into  the  nasal  membrane  along  the  olfac- 
torj''  nerves,  into  the  orbital  tissues  by  the  ophthalmic  and  optic,  etc. 
as  can  be  shown  experimentallj^ ;  but  this  method  of  escape  is  by 
far  the  least  important.  Most  of  the  fluid  passes  directlj^  into  the 
sinuses — into  the  longitudinal  sinus  in  particular.  Key  and  Retzius 
long  ago  expressed  the  view  that  the  escape  takes  place  through  the 
intervention  of  the  Pacchionian  granulations  which  project  into  the 
lacunae  laterales.  Foramina  of  exit  certainly  exist  in  this  situation, 
but  whether  the  ascape  of  fluid  takes  place  through  the  active 
agency  of  these  granulations  ma}'^  be  doubted;  for  the  free  escape 
of  fluid  by  the  sinuses  may  be  easily  demonstrated  in  infants  and 
in  the  higher  apes,  in  whom  no  Pacchionian  villi  exist.  Whether  at 
the  points  of  entry  of  fluid  there  exists  some  valvular  structure  akin 
to  the  valve  where  the  thoracic  duct  enters  the  jugular  or  whether 
there  be  some  other  mechanism,  matters  not  for  our  purpose;  the 
essential  thing  is  the  fact  that  the  chief  escape  takes  place  into  the 
venous  sinuses. 

With  this  knowledge  we  may  understand  how  infectious  processes 
may  block  these  channels  and  cause  stasis  of  the  cerebrospinal  fluid ; 
why  thrombosis  of  the  longitudinal  sinus  may  lead  to  serious  symp- 
toms, even  though  the  venous  anastomosis  may  be  sufficient  to  carry 
away  the  circulating  blood ;  why  congenital  hydrocephalus  is  so  fre- 
quently unassociated  with  any  demonstrable  lesion  of  the  region  of 
the  foramen  of  Magendie;  and  finally  why  many  of  our  operations 
directed  toward  the  cure  of  hydrops  ventriculorum  are  based  on 
wrong  principles  of  drainage. 


MENINGES,  EPENDYMA,  AND  BEAIN.  33 

BRAIN. 

Relation  to  skull. — The  fully  developed  brain  completely  fills  the 
cranial  chamber,  the  configuration  of  which  is  determined  under 
ordinary  circumstances  more  by  intracranial  influences  of  growth 
than  by  adventitious  extracranial  influences.  The  shape  of  the 
brain,  it  is  true,  may  be  modified  by  long-continued  pressure  against 
the  skull,  as  practiced  in  certain  barbaric  tribes,  but  it  is  doubtful 
vs^hether  the  total  quantity  of  brain  can  be  modified  by  any  such  in- 
fluence. Experimental  attempts  on  animals  to  restrict  cerebral 
growth  by  long-continued  extracranial  pressure  have  been  unavailing. 
This  matter  has  an  important  bearing  upon  a  form  of  treatment 
(linear  craniectomy)  proposed  for  cases  of  cerebral  maldevelopment, 
on  the  view  that  microcephalus  is  due  to  a  primary  closure  of  sutures 
which  prevents  cerebral  expansion,  rather  than  to  a  primary  insuffi- 
ciency of  brain  mass.  It  may  be  noted  in  this  connection  that  local 
cerebral  defects — whether  from  interrupted  growth  or  from  destruc- 
tive lesions  which  have  occurred  at  birth  or  during  infancy — often- 
times indicate  their  presence  by  the  flattening  of  the  overlying  por- 
tion of  skull.  Contrariwise,  the  cranium  in  the  young,  even  long 
after  the  sutures  have  closed,  yields  quickly  to  abnormal  growth  or 
increase  in  size  of  the  brain,  as  seen  in  cases  of  tumor  or  hydro- 
cephalus. 

Furthermore,  it  must  be  remembered  that  normal  variations  are 
great  not  only  between  the  brains  of  individuals,  but  between  those 
of  different  races.  In  individuals,  for  example,  there  may  be  a 
relatively  great  disproportion  between  the  amount  of  brain  matter 
anterior  and  that  posterior  to  the  central  fissure,  and  Froriep  refers 
to  two  types — the  "  frontopetal,"  in  which  the  greater  portion  of  the 
brain  lies  anterior  to  a  perpendicular  line  erected  at  the  auditory 
meatus,  and  the  "occipitopetal,"  in  which  it  is  posterior  to  this  line. 
And  in  these  two  forms  not  only  the  position  of  the  Rolandic  fissure, 
but  its  angle  of  obliquity  as  well,  is  greatly  altered.  There  is  prob- 
ably a  still  greater  variation  between  races.  Bean  has  pointed  out  the 
great  difference  in  the  size  and  shape  of  the  Caucasian  and  Ethi- 
opian brains,  particularly  as  regards  the  frontal  lobe.  It  is  in 
consequence  of  these  things  that  no  accurate  extracranial  measure- 
ments may  serve  to  indicate,  other  than  roughly,  the  situation  and 
the  form  of  the  central  or  other  cerebral  fissures. 

The  blood-supply. — The  chief  arterial  stems,  which  have  a  free 
intercommunication  through  the  circle  of  Willis,  supply  the  hemi- 
spheres through  three  main  branches:  (1)  The  anterior  cerebral  sup- 
plies the  first  and  second  frontal  convolutions  and  all  of  the  mesial 
surface  back  to  the  parieto-occipital  fissure;  (2)  the  middle  cerebral, 

13764^17 3 


34  WAR   SURGERY   OF   THE   NERVOUS   SYSTEM. 

emerging  at  the  Sylvian  fissure,  supplies  the  insula,  the  third  frontal, 
the  pre-  and  post-Rolandic  convolutions,  the  parietal  lobe,  the  first 
and  second  temporal  convolutions,  and  part  of  the  occipital  lobe — 
in  other  words,  most  of  the  exposed  outer  surface  of  the  hemisphere, 
and  (3)  the  posterior  cerebral  supplies  the  second  and  third  temporal 
gyri,  the  mesial  part  of  the  occipital  lobe,  and  the  under  surface  of 
the  temporosphenoidal  lobe.  The  vessels  to  the  deeper  structures  are 
given  off  directly  from  the  circle  of  Willis,  or  else  from  these  main 
stems ;  those  of  chief  moment  penetrate  and  supply  the  basal  ganglia. 
There  are  also  three  branches  of  considerable  size  which  arise  from 
the  vertebral  and  supply  the  cerebellum. 

The  occlusion  of  any  one  of  these  large  vessels  gives  characteristic 
and  localizing  signs,  and  operative  ligation  of  the  larger  stems  near 
the  base  of  the  hemisphere  must  be  undertaken  Avith  caution,  lest  it 
lead  to  softening  of  an  extensive  cerebral  area.  It  is  for  this  reason 
that  in  operations  for  tumors  it  is  desirable  to  ligate  the  individual 
twigs  in  the  environ  of  the  growth,  rather  than  the  main  branch 
at  a  distance.  This  applies  also  to  ligation  of  the  carotid,  for  in 
spite  of  the  usual  free  anastomosis  at  the  circle  of  Willis,  extensive 
softening  may  follow  this  operation. 

The  venous  circulation  within  the  brain  itself  and  over  the  cortex 
is  also  important.  Of  chief  interest  is  the  peculiar  arrangement  of 
vessels  which,  collecting  blood  from  the  basal  ganglia  and  from  the 
choroid  plexus,  unite  in  the  venae  Galeni,  which  in  turn  empty  into 
the  sinus  rectus.  Compression  of  these  latter  vessels,  or  their  occlu- 
sion from  any  cause,  leads  to  serious  symptoms  of  stasis  and  to  in- 
ternal hydrocephalus. 

The  vessels  of  the  hemisphere  course  over  the  surface  and  empty, 
for  the  most  part,  into  the  superior  sagittal  sinus  by  long,  oblique 
passages  directed  forward;  that  is,  against  the  current  in  the  sinus. 
The  two  largest  and  most  important  of  these  superior  cerebral  veins 
lie  in  or  near  the  central  or  the  two  adjoining  sulci ;  they  communicate 
freely  with  the  large  veins  lying  in  the  Sylvian  fissure.  Similar  large 
vessels  radiate  from  the  temporo-sphenoidal  lobe  and  enter  the  lateral 
sinuses.  The  points  of  attachment  or  anchorage  of  the  hemispheres 
to  the  dura  at  the  points  where  these  large  collecting  veins  cross  the 
subdural  space  are  of  prime  surgical  importance ;  they  occur  chiefly 
at  the  parasinoidal  sinuses  a  centimeter  or  two  from  the  mid-sagittal 
line;  also  at  the  occipital  pole,  under  the  temporal  lobe;  and  there 
is  in  addition  a  point  of  anchorage  at  the  outer  side  of  the  cerebellar 
hemisphere. 

It  is  undetermined  whether  the  cerebral  vessels  possess  vasomotor 
nerves.  By  intravital  methods  of  staining  it  is  possible  to  demon- 
strate nerves  which  are  histologically  akin  to  the  vasomotor  nerves 


MENINGES,   EPENDYMA,   AND  BRAIN.  35 

of  other  parts  of  the  body,  but  they  have  never  been  unequivocally 
shown  to  possess  a  dilator  or  constrictor  function.  Certainly  from 
the  results  of  experimental  observations  it  may  be  said  that,  even 
though  vasomotor  nerves  be  actually  present,  their  physiological 
action  differs  from  those  to  the  splanchnic  field  under  the  control 
of  the  vasomotor  center  in  the  medulla. 

The  lyiTvph  circulation  in  the  brain,  though  doubtless  abundant,  is 
of  a  peculiar  nature  not  well  understood.  It  has  been  demonstrated 
that  the  cerebrospinal  fluid — which  probably  has  no  direct  connection 
with  the  lymphatic  system — escapes  from  the  subarachnoid  space 
directly  into  the  larger  sinuses  and  thus  reaches  the  blood  stream 
without  the  intervention  of  glands.  Asher  has  shown  that  in  all  parts-, 
of  the  body  lymph  must  become  altered  in  its  passage  through  glands, 
before  it  enters  the  general  circulation ;  for  unaltered  it  is  very  toxic. 
It  Avould  be  surprising  should  there  prove  to  be  an  exception  to  this 
in  the  intracranial  lymph  circulation.  It  is  possible  that  lymphatics; 
from  the  surface  of  the  brain  may  pass  by  channels  through  the  cra- 
nial foramina  into  the  external  coverings  and  thus  in  the  cervical 
glands  without  any  actual  communication  with  the  subarachnoid 
space. 

Physiology  of  cerebral  circulation. — Certain  general  tenets  of  sur- 
gical import,  for  Avhich  we  are  in  large  part  indebted  to  Leonard 
Hill's  studies,  may  be  mentioned : 

The  bi-ain  pulsates  synchronously  v.itli  pulse  asid  respiration.  Its  greatest 
expansion  is  in  expiration,  due  to  the  accompanying  slight  venous  stasis.  The 
cardiac  pulse  is  transmitted  to  the  cerebral  veins.  These  movements  are  made 
possible  by  the  ebb  and  flow  of  cerebrospinal  fluid.  Any  increased  tension  of 
the  dura  mater  decreases  the  exhibition  of  the  cerebral  movements. 

As  there  is  no  evidence  of  the  existence  of  a  local  vasomotor  mechanism  it  fol- 
lows that  cerebral  anemia  from  ."^pasm  of  the  cerebral  arterioles  does  not  occur, 
though  it  must  be  confessed  that  clinical  evidence  furnished  by  cases  of  Ray- 
naud's disease,  in  which  local  cerebral  symptoms  occur,  speaks  against  thi-s 
view  of  the  experimentalists. 

According  to  the  "  Monro-Kellie  doctrine  "  the  total  quantity  of  blood  within 
the  cranium  is,  under  all  physiological  conditions,  practically  invariable.  The 
amount  of  blood  which  passes  through  the  cerel)ral  vessels  in  a  given  time  does, 
however,  vary  in  wide  limits. 

Under  normal  circumstances  the  intracranial  pressure  may  vary  considerably 
[between  0  and  50  mm.  of  Hg.  (Hill)]  from  circulatory  alterations  alone, 
brought  about  by  changes  in  position,  straining,  etc.  Venous  congestion,  when, 
kept  up,  may,  however,  become  of  great  pathological  significance. 

Conditions  of  disease,  on  the  other  hand,  leading  to  the  presence  of  a  new 
body  in  the  brain — a  clot,  a  tumor,  hydrocephalus,  etc. — materially  affect  the 
amount  of  blood  in  the  brain.  They  lead  primarily  to  venous  congestion,  andl 
only  to  arterial  anemia  when  the  pressure  due  to  the  crowding  of  the  new  body 
exceeds  the  general  arterial  pressure.  Even  under  these  circumstances  anemia 
is  for  a  time  overcome  by  a  compensatory  rise  in  arterial  tension,  due  largely 
to  constriction  of  the  splanchnic  field.  The  cerebral  sinuses  are,  in  a  measure;, 
compressible. 


36  WAE   SUKGERY   OF   THE    NERVOUS   SYSTEM. 

Under  many  circumstances  gravity  plays  an  important  rdle  in  cerebral  circu- 
lation, the  vasomotor  splanchnic  mechanism  being  the  regulatory  agent  and  one 
which  is  more  perfect  in  its  action  in  upright  animals  than  in  those  normally  on 
"  all  fours."  Inefficiency  of  the  splanchnic  constrictors  due  to  injuries,  to 
chloroform,  etc.,  is  of  vital  importance,  as  the  lowered  pressure  lessens  the 
cerebral  circulation  and  leads  to  anemia.  Hence  the  feet-down  position  when 
the  splanchnic  compensation  fails  may  lead  to  a  cessation  of  cerebral  circula- 
tion, with  fainting  and  even  death.  Some  form  of  support,  like  Crile's  rubber 
suit,  alone  will  justify  this  position  when  the  vasomotor  system  is  affected. 

In  cerebral  anemia,  whether  due  to  vasomotor  paralysis  and  posture,  to  blood- 
letting, to  occlusion  of  important  vessels  by  operation  or  disease,  symptoms 
occur  which  are  comparable  with  those  of  asphyxia.  There  is  first  uncon- 
sciousness, followed  by  slow  pulse  and  rise  in  blood  pressure;  later  by  a  fall 
in  blood  pressure,  a  rapid  pulse,  and  death. 

The  rapid  occlusion  of  the  main  source  of  arterial  blood  (the  two  carotids)  is 
likely  to  lead  to  fatal  symptoms  of  anemia ;  their  gradual  occlusion  can  safely 
be  carried  out  by  some  such  measui-e  as  Halsted  has  described. 

The  tension  of  the  cerebrospinal  fluid  and  cerebral  venous  pressure  is  nor- 
mally the  same.  If  the  former  is  increased  over  the  latter  the  fluid  escapes 
into  the  sinuses  (unless  they  are  occluded).  If  the  venous  pressure  becomes 
greater  than  the  cerebrospinal  fluid  tension  there  is  a  damming  back  of  cerebro- 
spinal fluid. 

Localization  of  functioii. — It  was  the  teaching  of  Flourens  that  all 
parts  of  the  cortex  possessed  the  same  significance ;  his  view  being  that 
lesions  of  the  hemispheres  would  produce  depression  of  function 
merely  according  to  their  extent,  but  regardless  of  their  situation. 
Thus,  the  phrenologists.  Gall  fnid  Spurzheim,  with  their  somewhat 
visionary  hypotheses,  were,  in  principle,  nearer  the  truth  in  their  ter- 
ritorial subdivisions  than  their  more  distinguished  contemporary. 
From  clinical  observations,  Broca,  in  1861,  by  demonstrating  the  seat 
of  articular  language;  Hughlings  Jackson,  in  1864,  as  a  result  of  the 
study  of  focal  epilepsy  and  Bastian,  in  1869,  through  further  obser- 
vations on  disturbance  of  speech,  undermined  in  a  measure  the  doc- 
trines of  Flourens ;  but  they  did  not  completely  crumble  to  the  ground 
until  1870  when  my  experimental  methods  Fritsch  and  Hitzig  demon- 
strated that  there  were  areas  of  the  dog's  cortex  which  gave  excitomotoi 
responses  to  galvanic  stimulation.  Ferrier,  in  1873,  using  the  faradic 
current,  verified  and  amplified  their  observations,  and  the  subsequent 
studies  of  Burdon  Sanderson,  Munk,  Schiff,  Schafer,  Horsley,  Mott, 
Bianchi,  and  a  host  of  others  have  served  to  fully  establish  the  theory 
of  separate  localization  of  cortical  function.  The  results  of  these 
clinical  and  experimental  researches  have  lately  received  further 
confirmation  by  embryological  and  histological  studies,  notable 
among  which  are  Flechsig's  observations  on  the  periods  of  myelini- 
zation  of  the  separate  tracts,  and  the  investigations  b}^  Mynert,  Betz, 
Ramon  y  Cajal,  and  more  recently  by  Campbell,  which  have  thrown 
light  on  the  structural  differences  of  the  various  cortical  areas. 

The  localization  theory,  however,  was  not  received  without  oppo- 
sition on  the  part  of  many  clinicians  and  experimentalists,  not  a  few 


MENINGES,    EPENDYMA,   AND   BEAIN,  37 

of  whom,  like  Goltz,  were  led  to  interpret  their  expei'i mental  observa- 
tions as  an  aro^ument  against  the  localization  of  function.  Even 
among  those  who  supported  the  theory  in  general,  disagreements  have 
occurred  in  regard  not  only  to  the  delineation,  but  also  to  the  exact 
function  of  particular  areas.  The  chief  strife  has  been  waged  over 
the  so-called  sensorimotor  cortex  in  the  elfort  to  determine  whether 
there  was  a  separate  or  a  superimposed  field  of  representation  for 
sensory  perception  and  motor  discharge.  Doubtless  the  chief  reason 
for  adherence  to  the  view  of  superimposition  of  these  areas  was  due 
to  the  fact  that  lesions  of  the  supposed  motor  field,  at  a  time  when 
motor  centers  were  thought  to  lie  both  anterior  and  posterior  to  the 
central  fissure,  often  led  to  sensory  disturbances.  We  now  know, 
through  the  more  accurate  methods  of  cortical  stimulation  introduced 
by  Sherrington  and  Griinbaum  (1901) ,  that  that  portion  of  the  cortex 
which  is  directly  excitable  by  a  unipolar  electrode  consists  of  a  nar- 
row strijD  which  lies  anterior  to  the  central  fissure  and  extends  to  the 
depth  of  this  fissure  on  its  anterior  surface  alone.  This  circumscrip- 
tion of  true  "  motor  cortex,"  together  with  the  subsequent  histological 
demonstration  that  this  zone  corresponds  exactly  to  the  distribution 
of  the  Betz  cells,  has  finally  led  to  the  general  view  that  the  central 
fissure  divides  the  cortex  into  an  anterior  motor  and  a  posterior 
sensory  field,  intricate  though  the  commissural  connections  between 
these  two  fields  may  be.  Sherrington  and  Griinbaum's  observations 
on  the  higher  anthropoids  have  been  confirmed  for  man  by  Krause, 
Frazier,  and  the  author. 

The  excitomotor  cortex. — This  is  limited  to  a  narrow  strip,  1 
centimeter  or  more  in  width,  of  the  exposed  part  of  the  gyrus  cen- 
tralis anterior^  but  extends  to  the  depth  of  the  -flssura  centralis  {Ro- 
landi).  Hence  its  chief  portion  is  not  on  the  visible  surface,  and 
consequently  a  lesion  which  actually  involves  the  motor  cortex  may 
lie  far  below  the  exposed  surface  of  the  hemisphere.  The  anterior 
edge  of  the  excitable  area  shades  off  without  sharp  demarcation ;  its 
upper  limit  overlaps  slightly  onto  the  mesial  surface  {lobulus  fara- 
centralis)  and  its  lower  limit  falls  short  of  the  Sylvian  fissure. 

The  Rolandic  fissure  is  not  a  straight  line,  but  is  broken  by  two,  or 
sometimes  three,  more  or  less  well-developed  angles  (genua),  formed, 
I  believe,  by  the  swellings  above  and  below  them,  made  by  the  aggre- 
gations of  cells  controlling  movements  in  leg,  arm,  face,  and,  still 
lower  down,  jaws,  tongue,  etc.  Opposite  to  the  upper  two  genua  the 
motor  strip  is  less  wide  and  its  representative  movements  less  com- 
plex, occurring  as  they  do  in  neck  and  trunk.  Thus,  the  genua  are 
valuable  surgical  landmarks,  particularly  the  middle  and  inferior 
ones,  for  they  are  more  often  brought  into  view.  Above  the  superior 
genu  there  is  but  a  small  triangle  of  motor  cortex  which  can  be  ex- 
posed, and  it  gives,  on  stimulation,  movements  in  hip,  knee,  and  toes; 


38  WAR   SUEGERY   OF   THE   NERVOUS   SYSTEM. 

opposite  to  this  genu  lie  centers  for  movements  of  thorax  and  ab- 
domen ;  between  it  and  the  middle  genu  lie  centers  for  the  upper  ex- 
tremity, the  shoulder  being  represented  higher  than  fingers  and 
thumb;  opposite  to  the  middle  genu  are  centers  for  the  neck  and 
below  it  those  of  the  face — eyelids  above  and  lips  below ;  centers  for 
jaws,  tongue,  vocal  cord,  pharynx,  etc.,  are  still  lower,  usually  below 
an  inferior  genu. 

Extirpation  of  these  areas  leads  to  loss  of  movement,  which  is 
more  or  less  complete  and  permanent  according  to  the  totality  of  the 
extirpation  and  to  the  degree  of  bilateral  representation  of  the  par- 
ticular movements  concerned.     Sensation  is  not  affected. 

Certain  complex  movements  of  a  higher  order  may  be  obtained  by 
simulation  of  areas  adjoining  the  true  motoi'  cortex.  Thus,  below  the 
gyrus  centralis  anterior^  in  the  pars  oferculaTis.  sucking,  chewing, 
sneezing,  and  vocalizing  movements  may  be  obtained  (note  that  this 
is  near  the  vocal  speech  center  of  Broca)  ;  and  from  the  gyrus  fron- 
talis medius  movements  of  the  head  and  eyes  to  the  opposite  side 
may  be  elicited. 

The  pathway  from  the  motor  cortex  is  the  pyramidal  tract,  whose 
fibers  degenerate  throughout  their  full  length  after  injury  to  their 
cortical  cells. 

The  sensory  field. — It  has  long  been  known  that  lesions  near  the 
-fissura  centralis  often  lead  to  sensory  disturbances.  The  observa- 
tions of  Sherrington  and  Grlinbaum,  showing  that  the  posterior  con- 
fines of  the  motor  cortex  lie  in  the  floor  of  the  fissure,  paved  the  way 
for  further  study  of  the  gyrus  centralis  posterior^  and  Campbell's  re- 
searches in  particular  would  seem  to  show  that  the  primary  regis- 
tration of  "  common  sensation  "  occurs  there.  He  has  demonstrated 
that  histological  changes  are  found  in  the  cortical  cells  of  this  gyrus 
after  amputations,  in  tabes,  etc.  The  area  occupies  much  the  same 
position  posteriorly  in  regard  to  the  fissura  centralis  that  the  motor 
area  holds  anteriorly.  It  is  largely  hidden  from  view  on  the  poste- 
rior surface  of  the  fissure  and  does  not  extend  back  over  more  than 
the  anterior  half  of  the  exposed  postcentral  gyrus, 

I  have  had  occasion  to  learn,  from  extirpations  of  the  postcentral 
gyrus  in  cases  of  focal  epilepsy  with  a  sensory  aura,  that  temporary 
sensory  disturbances  of  the  cortical  type  occur  after  such  lesions.  It 
is  to  be  noted,  furthermore,  that  some  disturbance  of  motion  follows 
such  extirpations,  but  a  palsy  of  this  type  is  due  to  loss  of  afferent 
impulses  and  is  unassociated,  as  I  have  found  in  two  cases,  with  any 
degeneration  of  the  pyramidal  tract. 

The  fibers  to  the  sensory  field  pass  from  the  thalamus  in  the  "  cor- 
tical lemniscus"  (Monakow)  of  the  corona  radiata  to  the  post-Ro- 
landic  territory.  In  their  course  they  lie  in  the  posterior  part  of  the 
oapsula  interna. 


MENINGES,  EPENDYMA,  AND  BKAIN.  39 

The  forms  of  sensation,  registration  of  which  we  may  now,  with 
some  assurance,  place  in  the  near  postcentral  region,  are  the  tactile 
gense,  the  muscular  sense,  and  the  power  of  discriminating  points  in 
contact.  It  is  evident  also  that  as  one  goes  further  back  from  the 
flssura  centralis  and  ajDproaches  the  posterior  association  field  of 
Flechsig,  sensation  becomes  more  complex,  so  that  more  extensive  and 
deeper  lesions  are  necessary  to  interrupt  its  transmission.  The  senses 
of  pain  and  of  temperature  lie  probably  in  the  intermediate  post- 
central zone  of  Campbell  and  that  for  the  recognition  of  objects — 
the  stereognostic  sense  in  particular — is  located  as  far  back  as  in  the 
parietal  lobe. 

The  visual  cortex. — Practically  all  investigators  agree  in  placing 
the  primary  receiving  station  for  visual  impressions  in  the  occipital 
lobe,  particularly  on  its  mesial  surface  in  the  calcarine  region.  The 
investing  (visuo-psychic)  field  is  concerned  with  "the  final  elabora- 
tion and  interpretation  of  these  sensations."  Myelinization  of  the 
fibers  to  the  former  occurs  early ;  of  those  to  the  latter,  not  until  the 
child  is  capable  of  interpreting  visual  stimuli. 

The  visuo-psychic  field  extends  on  the  outer  surface  (of  the  left 
side)  in  the  second  occipital  convolution  as  far  as  the  angular  gyrus, 
where  lies  the  visual  word  center  (reading)  which  participates  in 
the  speech  mechanism.  The  lingual  lobule  below  the  flssura  cal- 
carina  appears  to  be  associated  with  color  perception. 

The  auditory  cortex. — Auditory  impulses  appear  to  be  received 
primarily  at  some  portion  of  the  gyrus  temj^oralis  superior  and  to 
be  "  converted  into  conscious  perceptions  "  in  adjoining  parts  of  the 
temporal  lobe,  those  on  the  left  side  in  particular  being  concerned 
with  the  auditory  end  of  the  speech  mechanism.  Extensive  lesions 
on  the  right  side  may  give  rise  to  no  appreciable  impairment  of 
hearing  on  the  same  side,  and  there  is  much  confusion  over  the  uni- 
laterality  or  otherwise  of  the  registration  of  auditory  impulses. 

The  elaboration  of  the  primary  stimuli  into  tone  perception,  word 
perception,  etc.,  occurs  in  the  outlying  districts,  namely,  in  the 
audito-psychic  area  which  envelopes  the  primary  receiving  station. 

The  olfactory  cortex. — The  lohus  yyriformAs  is  generally  regarded 
as  the  chief  cortical  center  for  olfaction,  but  there  is  a  division  of 
opinion  as  to  the  part  played  by  the  adjoining  areas  of  the  gyrus 
uncinatus^  cornu  Ammonis,  etc. 

The  gustatory  area,  like  the  above,  is  not  definitely  determined, 
but  it  also  lies  probably  at  the  lip  of  the  limbic  lobe,  in  the  neighbor- 
hood of  the  uncus.  This,  topographically  speaking,  would  place 
both  of  these  areas,  for  taste  and  smell,  in  a  situation  just  to  the 
outer  side  of  the  pituitary  fossa — a  matter  of  considerable  impor- 
tance, as  lesions  confined  to  this  area  of  the  limbic  lobe  not  only 
give  characteristic  symptoms,  but  are  surgically  approachable. 


40  WAE   SURGERY   OF   THE    NERVOUS   SYSTEM. 

The  four  cortical  areas  concerned  in  speech  in  right-handed  people. — 
(1)  The  center  for  the  recognition  of  spoken  words  lies  in  the  out- 
skirts of  the  primary  center  for  hearing  in  the  gyrus  temporalis  su- 
perior of  the  left  temporal  lobe.  This  doubtless  is  the  first  center 
concerned  in  the  development  of  the  faculty  of  language,  in  normal 
individuals,  at  least,  for  we  must  remember  that  speech  may  be 
acquired  primarily  through  the  sense  of  touch  as  exemplified  in 
Helen  Keller's  remarkable  case. 

(2)  Since  Broca,  and  until  the  recent  doubts  cast  upon  it  by  Marie, 
the  posterior  end  of  the  gyrus  frontalis  inferior  has,  by  common 
consent,  been  regarded  as  harboring  the  centers  for  motor  or  vocal 
speech.  These  auditory  and  vocal  word  centers — Wylie's  "  primary 
couple  " — may  be  developed  in  the  uneducated  with  but  little  fur- 
ther advance.  With  later  education  is  acquired  the  interpretation 
(reading)  and  the  making  (writing)  of  the  symbols  of  language. 

(3)  The  visual  word  center  concerned  in  reading  has  been  defi- 
nitely placed  in  the  gyrus  angularis  in  the  outskirts  of  the  visuo- 
psychic  field,  and — 

(4)  The  so-called  writing  center,  if  such  exists,  has  been  placed 
at  the  posterior  end  of  the  gyrus  frontalis  medius;  in  other  words, 
near  the  primary  centers  for  movements  of  the  hand  and  fingers.  It 
is  not  improbable  also  that  there  is  a  fifth  center  in  the  parietal  lobe, 
associating  the  sense  of  touch  with  the  speech  mechanism.  It  is  to 
be  remembered  that  no  part  of  the  speech  mechanism,  so  far  as  its 
cortical  centers  are  concerned,  can  be  upset  without  affecting  in  some 
degree  all  other  parts,  though  the  most  serious  disturbances  result 
from  lesions  of  one  of  the  "  primary  couple." 

The  association  fields. — Other  parts  of  the  cortex  than  those  which 
have  been  described  are  concerned,  so  far  as  is  known,  only  with 
the  complex  processes  of  association,  and  lesions  of  these  areas  are 
largely  "  silent,"  so  far  as  our  present  possibilities  of  neurological 
examination  go.  An  exception  may  be  made  in  the  case  of  the  frontal 
lobes,  particularly  the  "  prefrontal "  portion  of  the  left  hemisphere, 
where  the  higher  psychic  or  intellectual  faculty  has  been  placed  by 
many  observers. 

THE  SYMPTOMATOLOGY  OF  ORGANIC  LESIONS. 

Although  the  cerebrum  is  subject  to  a  great  variety  of  morbid 
conditions,  the  symptoms  which  are  manifested  thereby  are  relatively 
few.  In  diseases  of  the  nervous  system  they  depend  in  general  more 
upon  the  situation  of  the  process  than  upon  its  nature.  Thus,  an 
obstructive  lesion  of  the  motor  path,  at  any  point  between  the  cortex 
and  the  peripheral  end-organs,  results  in  paralysis,  whether  it  be  due 


MEjSTjSTGES,  EPE>rDTMA.    \l"-   3EAI>'.  41 

to  a  neoplasm,  a  vascnlar  lesion  (hemorrhage,  thrombosis,  or  em- 
bolism) ,  inflammation,  injnry,  ecHnpression.  or  what  not. 

In  a  broad  sense  the  symptoms  may  be  dirided  into  (1)  subjective 
symptoms,  appreciated  only  by  the  patient,  and  objective  ones,  which 
are  obvious  to  the  observer:  (2)  general  symptoms,  or  those  which 
characterize  many  intracranial  processes  regardless  of  their  seat,  and 
focal  ones,  which  indicate  the  ^toation  of  the  lesion.  Snbjective  or 
objective  symptoms  may  be  general  or  focal,  and  vice  versa :  general 
or  focal  symptoms  may  be  either  largely  subjective  or  objective.  For 
example,  a  tnmor  involving:  the  cortical  center  of  the  left  hemisphere, 
which  presides  over  movements  of  the  arm,  may  give  aibjective  symp- 
toms which  are  general  and  dne  to  pre^mre.  such  as  diffnse  headache, 
nansea,  or  dizziness;  or  it  may  give  others  which  are  focal,  as  weak- 
ness or  dimini^ied  sensibility  in  tiie  arm.  It  may  give  objective 
symptoms  which  are  general,  as  shown  by  vomiting,  choked  disk,  and 
slowed  pulse,  or  ones  which  are  focal,  snch  as  mnscnlar  atrophy. 
brachial  spasticity,  or  a  monopl^ic  spasm. 

The  symptoms,  broadly  speaking,  may  farther  be  divided  into  thoe& 
which  are  irritative  and  those  which  are  paralyffic.  These  again  may 
be  general  or  focal,  sabjective  or  objective. 

General  symptoms. — These  are  headaches-  vomiting,  choked  disk, 
and  other  evidences  of  venons  stasis,  vertigo,  convulsions,  etc. 

Headache. — ^This  is  of  common  occnrrence  (1)  in  association  wkh 
a  variety  of  conditions  not  primarily  cerebral :  bnt  a  patient  snbject 
to  persisting  headaches  should  rest  nnder  the  suspicion  of  having^ 
primary  intracranial  disease  until  this  can  be  definitely  disproved^ 
Cephalalgia  of  extracranial  ©ri^ui  accompanies  chronic  processes  in 
the  mastoid  or  accessory  anuses,  eye  strain,  etc.  (the  so-called  reflex: 
headaches) .  anemia,  disturbances  of  digestive  or  menMrual  fonctiony 
fevers,  etc. 

Headache  (2)  is  almost  invariable  in  disease  of  the  meninges,  par- 
ticularly when  the  sentient  dura  is  involved,  and  it  is  my  impression 
that  most  headaches — those  of  the  migrainous  as  well  as  of  other 
types — are  largely  dural  in  origin.  This  membrane  is  innervated 
entirely  by  the  trigeminus,  with  the  exception  of  a  ^ooall  area  about 
the  foramen  magnum  supplied  by  vagal  fibers.  As  the  recurring  pain 
of  "  hemicrania  ^  is  a  not  infrequent  antecedent  of  facial  neuralgia, 
this  may  possibly  be  considered  as  a  form  of  dural  (trigeminal) 
neuralgia.  The  headaches  of  meningeal  inflammation,  particularly 
of  the  luetic  type,  may  be  profound. 

Of  chief  importance,  however,  are  the  headaches  (3)  due  to  intra- 
cranial pressure  fi'om  any  cause  whatsoever.  In  tumor,  ed^ooa 
(whether  of  traumatic  origin  or  associated  with  nephritis),  internal 
hydrocephalus,  serous  meningitis,  etc.,  the  pain  is  doubtle^:  brou^Ut 
about  bv  abnormal  tension  of  the  dura  or  of  its  membranous  ex- 


42  WAR   SUEGERY   OF    THE   NEEVOUS   SYSTEM. 

pansions  into  falx  and  tentorium.  As  a  rule,  headaches  due  to 
pressure  are  of  no  particular  help  in  localization,  for  regardless  of 
the  seat  of  the  lesion,  they  may  be  referred  to  the  A^ertex,  to  the 
frontal  region,  or  to  the  occiput.  Occasionally,  however,  taken  in 
conjunction  with  other  symptoms,  their  situation  may  be  helpful — 
as  in  certain  subtentorial  lesions  in  which  the  chief  discomfort  may 
be  referred  to  the  corresponding  suboccipital  area.  This  is  especially 
true  of  local  headaches  which  are  associated  with  an  area  of  tender- 
ness. 

There  are  all  gradations  of  headache,  from  a  dull  sense  of  pressure 
or  fullness  to  agonizing  and  prostrating  pain. 

Vomiting,  with  or  without  nausea,  and  irrespective  of  any  gastric 
disturbance,  is  a  common  symptom  of  any  acute  or  chronic  cerebral 
lesion,  especially  of  those  which  encroach  upon  the  intracranial  space. 
It  may  be  an  early  symptom  of  concussion  or  contusion;  and  more 
or  less  nausea,  doubtless  due  to  the  secondary  edema,  may  persist 
after  these  acute  traumatic  lesions  for  days.  In  chronic  processes  it 
is  an  even  more  characteristic  symptom.  Sudden  projectile  vomiting, 
often  accompanied  by  nausea,  is  well  known  as  a  general  symptom 
of  pressure  resulting  from  brain  tumor,  from  the  edema  of  nephritis, 
etc.  The  physiology  of  the  process  is  not  determined.  Some  believe 
that  there  is  an  especial  center  in  the  medulla,  irritation  of  which 
leads  to  vomiting. 

Vertigo  is  a  frequent  subjective  phenomenon,  but  being  a  common 
symptom  from  causes  other  than  cerebral  ones  it  is  of  importance 
only  in  association  with  other  evidences  of  organic  disease  of  the 
brain.  It  is  most  pronounced  in  lesions  which  involve  the  auditory 
nerve,  the  mid-brain,  or  cerebellum. 

Choked  disk  ("optic  neuritis"),  if  of  a  degree  sufficient  to  cause 
dimness  of  vision,  may  be  a  subjective  as  well  as  an  objective  phe- 
nomenon. It  is  one  of  the  most  important  indications  of  intracranial 
pressure,  and  an  ophthalmoscopic  examination  should  be  made  upon 
every  case  in  which,  from  headache  alone,  there  may  be  a  suspicion 
of  intracranial  disease.  It  is  not  sufficient  for  the  examiner  to  be 
able  to  recognize  a  choked  disk  when  it  is  full-blown,  but  the  slight 
edema  of  retina  and  nerve  head  with  early  distension  and  tortuosity 
of  the  veins  which  precedes  actual  "choking,"  must  be  appreciated, 
for  they  are  of  the  utmost  help  in  making  an  early  diagnosis.  The 
symptom,  on  the  wliole,  is  merely  an  evidence  of  general  pressure, 
although  occasionally  a  unilateral  choking  or  a  process  more  ad- 
vanced in  one  side  than  the  other  may  have  a  certain  localizing  value 
and  suggest  the  presence  of  disease  upon  the  corresponding  side  of 
the  head.  As  a  matter  of  fact,  however,  the  most  pronounced  cases 
of  choked  disk  occur  in  association  with  subtentorial  processes, 
the  stasis  in  the  eye  grounds  being  brought  about  by  an  obstructive 


MENINGES,   EPENDYMA,   AND  BEAIN,  43 

hydrocephalus;  and,  inasmuch  as  this  leads  to  a  general  and  equal 
increase  of  pressure  the  process  on  the  two  sides  will  be  equal  in 
degree,  unless  there  chances  to  be  some  structural  difference  in  the 
sheaths  of  the  two  optic  nerves. 

Many  theories  have  been  advanced  in  explanation  of  this  phe- 
nomenon. The  more  important  views  are  those  of  von  Graefe 
(1860),  who  thought  that  it  was  due  to  compression  of  the  cavern- 
ous sinus  leading  to  venous  stasis  in  the  eye.  The  Schmidt-Manz 
'•'"TrarhsportfJieorie'''  (following  the  discovery  of  Schwalbe  that  the 
intravaginal  space  of  the  optic  nerve  communicates  with  the  inter- 
meningeal  spaces  of  the  brain)  attributes  a  choked  disk,  in  cases  of 
increased  pressure,  to  the  stasis  of  cerebrospinal  fluid  into  this  space, 
leading  to  an  ampullalike  distension  of  the  optic  sheath.  Parinaud 
(1879)  thought  that  a  choked  disk  could  only  occur  in  association 
with  internal  hydrocephalus  or  other  conditions  associated  with  an 
edema,  which  was  supposed  to  spread  along  the  optic  nerve  from 
the  brain  itself.  Von  Leber  (1881)  expressed  the  view  that  it  was 
an  actual  inflammation — a  "papillitis" — brought  about,  irrespective 
of  edema  or  stasis,  by  the  growth;  just  as  a  "neuroretinitis"  is  said  to 
be  caused  by  circulating  toxic  products  in  chronic  renal  disease. 
Other  theories — that  it  is  of  reflex  origin;  that  it  is  due  to  sympa- 
thetic disturbances,  etc. — have  been  advanced,  but  they  are  less  widely 
supported. 

Generally  speaking,  we  see  that  there  are  mechanical  views  opposed 
to  toxic  views,  each  of  which  has  been  upheld  by  a  number  of  eminent 
clinicians  and  investigators ;  but  the  general  employment  of  the  term 
optic  "neuritis"  would  seem  to  indicate  that  it  is  widely  regarded  as 
an  inflammatory  process.  Eecent  clinical  and  experimental  observa- 
tions showing  the  rapid  subsidence  of  a  choked  disk  after  decompres- 
sive operations,  serve  to  modify  the  views  wdiich  manj^  have  held,  and 
with  Sanger,  Axenfeld,  and  others  I  believe  that  almost  all,  if  not 
all  cases  of  choked  disk  are  primarily  of  mechanical  origin  and  do 
not  justify  the  term  "neuritis."  It  is  a  quibble  to  say  that  the 
transudation  of  fluid  anywhere  is  necessarily  associated  with  some 
toxic  agency,  but  the  stasis  edema  which  occurs  in  consequence  of 
the  application  of  a  tourniquet  on  an  extremity,  though  toxic  in  a 
sense,  is  more  properly  considered  mechanical,  since  the  removal  of 
the  mechanical  agent  and  relief  of  the  stasis  allows  the  edema  rapidly 
to  subside. 

When  the  swelling  of  a  choked  disk  has  become  pronounced  and  has 
been  of  sufficiently  long  duration  hemorrhages  occur  in  the  nerve  head 
and  retina  as  a  result  of  the  stasis;  this  is  followed  by  an  infiltra- 
tion of  round  cells,  and  unless  the  process  is  cliecked  organization 
progresses  until  the  fibers  become  physiologically  "  blocked "  and 
light  is  no  longer  transmitted.     The  loss  of  vision  occurs  primarily 


44  WAR   SURGERY   OF   THE    NERVOUS   SYSTEIM. 

as  a  peripheral  shrinkage  of  the  field  for  form  and  color,  and  it 
must  always  be  remembered  that  normal  acuity  of  central  vision  may 
remain  oftentimes  until  late  in  the  process. 

Other  less  important  general  symptoms  may  be  mentioned,  among 
them  convulsio7is,  which  in  this  case  are  invariably  associated  with, 
loss  of  consciousness.  They  may  occur  even  when  there  is  a  local 
lesion  and  yet  not  be  indicative  of  its  situation,  for  only  when  the  le- 
sion involves  primarily  some  center,  irritation  of  which  leads  to 
symptoms  w^hich  can  be  appreciated  by  the  patient  during  conscious 
moments  or  can  be  observed  by  the  onlooker  before  the  convulsion, 
becomes  general,  can  their  seat  of  origin  be  determined.  Focal  le- 
sions, therefore,  apart  from  the  so-called  motor  fields,  may  lead  to  a 
general  rather  than  a  focal  convulsion.  General  convulsions  of  cere- 
bral origin  involving  the  entire  musculature  may  arise  from  toxic 
causes  apart  from  any  organic  lesion ;  such  are  especially  common  in. 
children. 

Grades  of  stupor  are  usual  in  almost  all  intracranial  processes, 
especially  when  acute  or  subacute.  They  may  vary  from  simple 
drowsiness,  with  j^aAvning,  etc.,  to  profound  sleep  from  which  the 
patient  can  not  be  aroused ;  to  lethargy,  in  which  he  is  totally  indif- 
ferent to  his  condition,  even  though  seemingly  awake;  to  stupor,  in 
which  he  is  oblivious  of  his  surroundings,  though  in  its  lighter  grades 
he  may  be  aroused  so  as  to  respond  to  questions,  of  which  he  has  no 
subsequent  memory;  to  coma,  with  profound  unconsciousness  and 
usually  with  serious  respiratory  symptoms.  Corresponding  degrees 
of  unconsciousness  may  be  of  toxic  origin  and  occur  in  acute  alcohol 
poisoning,  in  diabetes,  etc.,  or  they  may  be  due  to  circulatory  dis- 
turbances, whether  from  acute  anemia  or  from  the  venous  stasis 
brought  about  by  intracranial  pressure.  They  not  only  accompany 
all  cranial  injuries  of  any  severity,  due  to  the  pressure  of  hemor- 
rhage, edema,  etc.,  but  they  also  occur  in  meningitis  and  internal 
hydrocephalus  as  well.  When  unconsciousness  is  profound  and  re- 
sults in  coma  it  is  clinically  of  great  importance  to  distinguish  be- 
tween its  possible  sources  of  origin — apoplexy  (whether  spontaneous 
or  traumatic),  sunstroke,  alcoholism,  uremia,  narcotic  poisoning,  dia- 
betes, epilepsy,  etc. 

Inso?nnia,  emaciation^  variations  from  the  normal  of  pulse^  of  res- 
firaiion^  of  hody  temjyerature^  of  urinary  secretion^  may  be  regarded 
as  general  symptoms  in  certain  cases. 

Focal  symptoms. — We  have  heretofore  considered  merely  the  gen- 
eral symptoms  Avhich  indicate  the  j^resence  of  intracranial  disease. 
When  focal  symptoms  are  present  they  may  enable  us  to  determine 
its  situation.  Eoughly  speaking,  they  are  confined  to  disturbances  of 
motion,  of  common  sensation,  and  of  the  faculties  of  special  sense. 


MENINGES,   EPENDYMA,  AND  BRAIN.  45 

On  the  motor  side. — Motor  paralysis  is  the  most  evident  of  all  ob- 
jective signs.  Primarily  it  indicates  the  side  of  the  brain  involved. 
Less  clearly  it  shows  the  situation  of  the  involvement,  whether  corti- 
cal, subcortical,  capsular,  penduncular,  pontine,  or  medullary.  It 
may  be  hemiplegic  and  involve  an  entire  half  of  the  body,  or  only  the 
trunk  and  extremities.  It  may  be  monoplegic  and  involve  only  one 
extremity ;  paraplegic  when  the  legs  chiefly  are  aflfected ;  or  diplegic 
when  arms  and  legs  both  are  impaired.  Diplegia  is  a  more  usual  evi- 
dence of  spinal  than  of  cerebral  disease,  though  it  occurs  in  cases  of 
widespread  intracranial  hemorrhage  or  injury,  particularly  in  the 
so-called  "birth  palsies."  There  are  also  various  forms  of  multiple 
paraylsis,  in  which  individual  muscles  or  groups  of  muscles  supplied 
by  single  cerebral  nerves  may  be  involved. 

Paralyses  of  cortical  origin  are  apt  to  be  accompanied  or  pre- 
ceded by  irritative  symptoms,  and  are  more  commonly  monoplegic 
in  character.  Paralyses  of  capsular  or  peduncular  origin,  since  the 
fibers  of  the  pyramidal  tract  are  gathered  there  into  a  small  space, 
are  more  apt  to  be  hemiplegic.  The  so-cailled  "  crossed  paralysis  " 
is  one  in  which  a  cerebral  nerve  palsy  on  one  side  accompanies  paral- 
ysis of  the  limbs  on  the  opposite  side.  Motor  paralyses  of  pontine 
or  medullary  origin  rarely  fail  to  have  accompanying  symptoms, 
due  to  involvement  of  neighboring  structures. 

Spasticity  of  the  muscles,  with  increased  reflexes,  occurs  as  the 
result  of  a  lesion  of  the  intracranial  portion  of  the  motor  pathway. 
Should  the  lesion  take  place  in  the  young  there  may  be  marked  dis- 
turbance of  growth.  Contractures  occur,  whereby  the  limbs  become 
fixed  in  awkward  positions. 

Motor  irritation  is  evidenced  most  frequently  by  epileptiform 
seizures  or  convulsions.  Local  convulsions  in  the  form  of  monospasm 
is  a  common  indication  of  a  lesion  at  or  near  the  so-called  motor 
area.  The  process  leading  to  convulsions  may  be  a  quiescent  one — a 
cortical  defect;  the  cicatrix  of  an  old  healed  focus  of  hemorrhage, 
etc. — or  one  which  is  progressive,  as  an  enlarging  cyst  or  tumor.  A 
localized  convulsion  may  be  followed  by  paralysis;  a  general  one, 
by  a  condition  of  profound  muscular  exhaustion ;  and  when  fre- 
quently repeated  and  the  so-called  status  epilepticus  ensues,  death 
may  result  from  asphyxia  due  to  failure  of  respiratory  movements. 
Other  irregularities  of  movement — ataxic,  choreic,  athetoid,  etc. — are 
usually  the  result  of  lesions  in  organs  like  the  cerebellum  or  basal 
ganglia  which  modify  movements,  rather  than  of  those  affecting  the 
primary  conducting  path. 

On  the  sensory  side. — Like  those  of  motion,  sensory  disturbances 
may  result  from  cortical  or  subcortical  lesions.  They  also  may  be 
irritative  and  associated  with  subjective  symptoms  of  paresthesia, 
or  paralytic  and  accompanied  by  anesthesia. 


46  WAR   SURGERY   OP   THE   NERVOUS   SYSTEM. 

Anesthesia  may  be  complete  or  partial  (hypesthesia)  to  various 
forms  of  stimulation — to  pain,  touch,  pressure,  temperature,  etc. 
The  deeper,  as  well  as  the  cutaneous  sense,  may  be  affected  and  there 
may  be  loss  of  the  sense  of  posture  in  an  extremity,  or  of  its  position 
in  space.  Owing  to  the  fact  that  a  profound  sensory  paralysis  leads 
to  the  shutting  off  of  all  afferent  impulses,  a  certain  degree  of  motor 
impairment  is  an  almost  invariable  accompaniment.  On  the  other 
hand,  no  sensory  disturbance  need  accompany  motor  paralj^sis. 

Irritative  sensory  symptoms  may  precede  those  of  motion.  Thus, 
the  aura  or  warning  of  an  impending  convulsion  may  be  an  impor- 
tant clinical  sign  and  may  at  times  serve  to  indicate  the  situation 
of  the  lesion,  even  though  the  convulsion  itself  was  general  from  the 
onset.  The  warning  may  occur  as  a  subjective  sensory,  gustatory, 
visual,  or  olfactory  impression. 

Disturbances  of  special  sense  perception  may  be  secondary  not 
only  to  peripheral  lesions  of  the  nerves  themselves,  but  also  to  lesions 
of  the  cerebral  centers  where  special  sense  impressions  are  registered. 
A  lesion  may  pervert  or  destroy  any  of  the  special  sense  qualities — 
smell,  taste,  hearing,  and  sight. 

Craniocerebral  topography, — The  discovery  that  different  functions 
were  localized  in  particular  areas  of  the  brain,  and  the  knowledge — 
gradually  acquired — of  what  symptoms  were  produced  by  lesions 
limited  to  these  areas,  paved  the  way  for  surgical  measures  directed 
toward  their  relief.  It  thus  became  imperative,  particularly  in  the 
days  when  an  attempt  was  made  to  approach  these  lesions  through 
a  small  trephine  opening,  that  the  relationship  of  the  cerebral  con- 
volutions and  fissures  to  the  surface  markings  of  the  skull  should  be 
established  with  the  greatest  possible  accuracy.  The  science  of 
craniocerebral  topography  arose;  and  a  great  number  of  investiga- 
tions have  since  been  devoted  to  the  establishment  of  certain  rules  of 
measurement,  which  give  us,  with  sufficient  accuracy,  the  average 
position  of  the  main  fissures  of  the  exposed  part  of  the  hemispheres 
in  their  relation  to  definitely  palpable  points  on  the  external  cranial 
wall. 

It  may  be  recalled  that  Paul  Broca  was  not  only  a  pioneer  in  these 
studies,  but  was  actually  the  first,  in  1871,  to  put  them  to  practical 
test  in  an  operation  performed  for  him  on  a  patient  with  aphasia  due 
to  an  abscess  in  the  third  left  frontal  convolution.  Since  then  im- 
portant contributions  to  the  subject  have  been  made,  and  particular 
rules  have  been  formulated  by  K.eid,  Cunningham,  Thane,  Horsley, 
Chipault,  Taylor  and  Haughton,  Poirier,  Dana,  Kronlein.  Chiene^ 
Anderson  and  Makin,  Le  Fort  and  Debierre,  Masse  and  Woolingham, 
Lannelongue  and  Mauclaire  (for  infants),  Miiller,  Froriep.  Kocher, 
and  many  others.  Each  of  these  prescribed  rules  has  its  good  points^ 
and  the  results  of  most  of  them,  when  applied  to  the  same  skull,  do 


MENINGES,   EPENDYMA,   AND   BKAIN.  47 

not  vary  much  more  than  a  centimeter  or  two.  For  the  most  part 
they  are  devoted  to  a  determination  upon  the  scalp  of  the  upper  and 
lower  ends  of  the  central  fissure  (superior  and  inferior  Rolandic 
points),  to  the  point  of  origin  of  the  Sylvian  fissure  (Sylvian  point), 
as  well  as  to  its  line  of  general  direction,  and,  less  important,  to  the 
occipitoparietal  fissure.  The  studies, have  been  based  largely  on  the 
average  measurements  of  adult  crania,  and  the  difficulty  of  establish- 
ing the  exact  relationship  of  the  encephalic  and  the  extracranial  land- 
marks has  been  overcome  by  a  variety  of  ingenious  devices. 

The  main  principles  of  the  superficial  delineation  of  the  fissures 
rest  (1)  upon  the  establishment  of  an  equatorial  base  line,  from  which 
perpendicular  meridians  or  lines  of  intersection  of  coronal  planes  are 
erected  at  given  points,  and  (2)  upon  angulation  at  given  points, 
either  from  this  base  line  or  from  parallel  circles,  or  from  the  mid- 
sagittal  meridian.  Reid's  base  line  is  the  favorite  among  English 
writers;  it  passes  through  the  lower  border  of  the  orbit  and  middle 
of  the  external  meatus  and  is  nearly  parallel  to  the  upper  border  of 
the  zygoma ;  the  German  base  line  differs  slightly  from  this  in  pass- 
ing through  the  upper  edge  of  the  meatus.  Perpendiculars  according 
to  various  rules  of  measurement  are  erected  (1)  at  the  preauricular 
point  between  tragus  and  maxillary  condyle;  (2)  from  this  condyle 
itself;  (3)  from  the  middle  of  the  zygoma;  and  (4)  from  the  posterior 
edge  of  the  mastoid  process.  Zones  parallel  to  the  base  line  ("  upper 
horizontals")  are  made  to  pass  through  the  upper  border  of  the 
orbit,  or  from  the  external  angular  process,  etc.  Use  is  made  also  of 
particular  points  of  union  of  the  sutures,  many  of  which  are  more  or 
less  definitely  palpable  and  for  which  time-honored  names  are  pre- 
ser^  ed — nasion,  inion,  pterion,  bregma,  asterion,  etc. 

A  few  of  the  better  rules  for  the  extracranial  determination  of  the 
chief  cerebral  fissures  may  be  given. 

The  sup'^rloT  Rolandic  fohit  is  found  on  the  midsagittal  line  55.(5 
per  cent  of  the  distance  from  glabella  to  inion  or  external  occipital 
protuberance  (Reid)  ;  or  one-half  this  distance  plus  one-half  to  three- 
fourths  inches  (Thane)  ;  or  one-half  the  nasio-inionic  line  plus  2  cm. 
(Poirisr).  or  2-]-  cm.  (Kocher)  ;  or  at  the  intersection  of  the  mid- 
sagittal  line  with  a  coronal  plane  erected  at  the  posterior  border  of  the 
mastoid  (Reid,  Kronlein)  ;  or  5  cm.  posterior  to  the  intersection  with 
a  coronal  plane  erected  at  the  preai^ricular  point  (Broca)  ;  or  2  to  3 
cm.  behind  the  coronal  suture  or  bregma  (Thane) . 

The  inf error  Rolandic  yoint  lies  on  the  fissure  of  Sylvius  25  mm. 
behind  its  bifurcation  or  Sylvian  point  (Thane)  ;  or  3f  inches  below 
the  s:ipeiif>r  Rolandic  point  on  a  line  which  makes  an  angle  of  from 
C7  to  71.5  degrees  with  the  midlongitudinal  line  (Cunningham)  ;  or 
7  ciii,  abo^e  the  pre-auricular  point  on  a  line  perpendicular  to  the 


48  WAR   SUEGEEY   OF   THE   NERVOUS   SYSTEM. 

zygoma  (Poirier)  ;  or  5.5  cm.  (varying  from  4  to  7)  above  the  zygoma 
on  or  slightly  in  front  of  this  pre-auricular  line  (Thane). 

The  Rolaridic  line  corresponds  with  a  meridian  dropped  from  the 
superior  Rolandic  point  and  making  an  angle  with  the  midsagattal 
line  of  67  degrees  (Hare)  ;  or  varying  from  64°  to  75°  (Thane),  li 
extended  below  the  inferior  Eolandic  point  it  should  cross  the  middle 
of  the  zygomatic  arch  (Le  Fort). 

The  Sylvian  point  may  be  located  at  the  intersection  of  two  lines ; 
'{1)  from  the  auditory  meatus  to  a  point  at  25  per  cent  of  the  nasio- 
inionic  line,  and  (2)  from  the  external  angular  process  to  a  point  at 
75  per  cent  of  nasio-inionic  line  (Taylor  and  Haughton)  ;  or  at  the 
intersection  of  lines  (1)  erected  perpendicular  to  the  base  line  at  the 
middle  of  the  zygoma  and  (2)  parallel  to  the  base  line  (upper  hori- 
zontal) through  the  upper  margin  of  the  orbit  (Kronlein)  ;  or  12 
mm.  above  a  horizontal  line  drawn  back  from  the  frontomalar  suture 
to  a  distance  of  35  mm.  (Thane). 

The  fissure  of  Sylvius  corresponds  with  a  line  joining  the  external 
angular  process  of  the  frontal  bone  and  the  point  of  intersection  of 
the  previously  determined  Eolandic  line  and  the  preauricular  per- 
pendicular line  (Reid)  ;  or  with  a  line  drawn  from  the  nasion  to  1  cm. 
TDelow  the  lambda  (Poirier)  ;  or  with  a  line  connecting  the  external 
angular  process  with  a  point  80  ptr  cent  of  the  distance  from  nasion 
to  inion  (Chipault)  ;  or  a  point  75  per  cent  of  this  distance  (Taylor 
and  Haughton)  ;  or  with  a  line  bisecting  the  acute  angle  made  by 
the  lines  (1)  from  the  superior  Eolandic  point  to  the  Sylvian  pomt 
and  (2)  from  the  upper  border  of  the  orbit  and  carried  parallel  to 
the  base  line  (Kronlein)  ;  or  with  a  line  from  the  external  angular 
process  to  a  point  at  the  junction  of  the  middle  and  lower  thirds  of 
the  line  connecting  the  preauricular  point  and  midsagiti^al  points 
(Anderson  and  Makins). 

The  'parieto-occipital  fissure  is  found  opposite  to  or  a  little  above 
the  lambda,  or  6^  cm.  above  the  inion  (Thane),  or  seven-eighths  of 
the  distance  from  the  midsagittal  point  to  the  inion  (Anderson  and 
Makins) . 

Aside  from  these  prescribed  rules  there  are  certain  general  points 
worthy  of  observation.  The  lower  level  of  the  temporal  lobe — in 
other  words,  the  floor  of  the  middle  cranial  fossa — lies  about  on  a 
level  with  the  zygoma,  and  the  lower  edge  of  the  occipital  lobe  cor- 
responds with  the  superior  curved  line  of  the  occipital  bone.  The 
Sylvian  point,  which  marks  the  bifurcation  of  the  Sylvian  fissure, 
corresponds  practically  with  the  pterion,  and  the  posterior  arm  of  the 
fissure  in  the  adult  underlies  the  anterior  part  of  the  parietosqua- 
mosal  suture  and  ascends  to  a  point  just  below  the  parietal  eminence; 
it  consequently  is  much  higher  than  one,  not  having  made  measure- 
ments, would  suppose,  for  the  center  of  the  fissure  is  fully  2  inches 


MENINGES,   EPENDYMA,   AND   BRAIN".  49 

above  the  zygoma.  The  motor  strip  lies  more  on  the  top  of  the 
hemisphere  than  on  the  side  and  is  entirely  under  the  parietal  bone ; 
hence  diagrams  which,  on  a  lateral  view,  show  much  more  than  the 
face  centers — that  is,  the  part  beloAv  the  middle  genu — are  incorrect 
and  confusing.  The  mid-point  between  inion  and  nasion  is  easily 
determined  and  practically  corresponds  with  a  perpendicular  erected 
from  the  base  line  at  the  meatus.  Though  this  lies  1  or  2  cm.  anterior 
to  the  superior  Eolandic  point,  a  meridian  at  60  degrees  dropped  from 
this  point  to  the  middle  of  the  zygoma,  as  Kocher  has  shown,  indi- 
cates the  general  direction  of  the  top  of  the  precentral  convolution ; 
and  this  meridian — in  view  of  Sherrington's  finding  that  there  is  no 
motor  cortex  posterior  to  the  central  fissure — is  as  simple  and  useful 
a  topographical  landmark  as  can  be  had  for  general  purposes. 

It  may  further  be  noted  that  the  Sylvian  point  marks  the  pole 
of  the  insula;  that  the  parietal  eminence  overlies  the  supramarginal 
gyrus;  the  frontal  eminence,  the  second  convolution;  the  anterio- 
inferior  angle  of  the  parietal,  the  inferior  frontal  (Broca's)  con- 
volution; that  the  temporal  lobe  lies  for  the  most  part  beneath  the 
squamous  wing  of  the  temporal  bone ;  the  parietal  lobe  entirely  under 
the  parietal  bone. 

As  to  the  deeper  stmctwes,  the  Sylvian  point  being  the  guide  to 
the  insula,  this  in  turn  covers  the  basal  ganglia,  as  has  been  pointed 
out  Avhen  speaking  of  its  early  formation.  The  lateral  ventricles 
curl  round  the  basal  ganglia  with  their  flat  surface  on  top  at  a  depth 
of  about  5  cm.  below  the  upper  surface  of  the  hemisphere.  If  they 
are  to  be  approached  for  aspiration  it  is  desirable  to  select  not  only  a 
site  where  little  harm  can  be  done  from  the  passage  of  the  needle, 
but  also  where  there  is  the  least  likelihood  of  missing  the  ventricle. 
Paths  of  election,  therefore,  are  (1)  the  superior  frontal  convolution 
to  the  area  where  the  ventricle  is  horizontally  wide  over  the  basal 
ganglia,  or  (2)  through  the  posterior  end  of  the  superior  temporal 
convolution  to  the  area  where  the  cavity  is  vertically  wide — namely, 
as  it  curls  around  the  ganglia  and  gives  off  its  temporal  and  occipital 
cornua. 

The  middle  meningeal  artery^  after  entering  the  skull  at  the  fora- 
men spinosum,  curves  forward  and  upward  on  the  dura,  covering 
the  tip  of  the  temporal  lobe,  to  the  anterio-inferior  angle  of  the 
parietal  bone,  which  it  deeply  grooves  or  channels.  The  pterion, 
therefore,  is  a  guide  to  the  vessel  in  this  part  of  its  course  where  it 
overlies  the  Sylvian  point;  but  for  purposes  of  ligation  the  vessel 
can  be  exposed  more  safely  by  trephining  in  the  middle  of  the  tem- 
poral fossa,  where  it  is  easily  approached.  The  attachment  of  the 
vessel  in  the  bone  at  these  two  fixed  points  is  to  be  observed  in  cer- 
tain extradural  operations  in  the  middle  fossa,  as  in  the  approach  to 
the  Gasserian  ganglion. 
1.3764—17 4 


50  WAR   SUEGEEY   OF   THE    NERVOUS   SYSTEM, 

It  can  be  seen  that  the  establishment  of  the  position  of  the  Rolandic 
fissure  has  been  the  chief  aim  of  these  investigations — an  evidence  of 
the  fact  that  a  large  proportion  of  intracranial  operations  have  been 
directed  toward  central  lesions  which  loudly  call  attention  to  their 
presence  by  paralyses  or  convulsions.  However,  even  in  this  care- 
fully studied  region— the  most  approachable  one  fo-r  the  surgeon — 
extracranial  measurements  are  not  to  be  implicitly  relied  upon  as 
guides  for  the  recognition  of  the  central  convolutions,  and  the  supple- 
mentary acquaintance  with  actual  cortical  topography  is  of  far 
greater  importance.  Too  great  dependence  on  the  former  may  be 
very  misleading.  Thus,  though  the  superior  Rolandic  point  can  be 
determined  upon  the  scalp  wath  a  small  margin  of  error,  this  informa- 
tion is  not  of  especial  value,  for  the  upper  end  of  the  central  fissure 
is  so  inaccessible,  owing  to  the  parasinoidal  sinuses,  etc.,  that  it  can 
rarely  be  exposed.  Furthermore,  the  fissure  makes  such  a  variable 
angle  with  the  median  line  (64  to  75  degrees)  and  is  so  sinuous  in 
its  dow^nward  course,  owing  to  the  variable  prominence  of  the  genua, 
that  even  though  the  superior  and  inferior  Rolandic  points  have  been 
accurately  determined,  the  line  connecting  them  at  the  prescribed 
angle  (averaging  67  degrees)  may  lie  from  1  to  2  cm.  (the  width  of  a 
convolution)  anterior  or  posterior  to  that  part  of  the  central  fissure, 
which  is  usually  brought  into  view  by  the  operation. 

These  things  are  mentioned,  not  to  deter  surgeons  from  studying 
craniocerebral  topography,  but  rather  to  point  out  that  topographical 
delineations  on  the  scalp  are  at  best  only  a  rough  indication  of  corti- 
cal landmarks  and  that  the  ability  to  recognize  these  after  exposure 
in  the  living  is,  after  all,  the  essential  thing.  This  presents  little 
difl&culty  so  far  as  the  Sylvian  fissure  is  concerned,  and  comes  with 
practice  in  the  case  of  the  central  fissure,  though  the  final  appeal 
must  often  be  made  to  faradization.  All  neurological  surgeons, 
through  abundant  practice  on  the  cadaver,  should  acquire  so  thor- 
ough an  acquaintance  with  the  precepts  of  craniocerebral  topog- 
raphy that  they  possess  the  ability  to  visualize  through  the  skull  not 
only  the  surface  markings,  but  also  the  deeper  structures  of  the 
encephalon,  unaided  by  elaborate  extracranial  measurements.  They 
should  know  the  brain  as  abdominal  surgeons  know  the  belly. 

INFLAMMATION"  OF  THE   BRAIN. 

Acute  encephalitis — P olio-ence'phalitis  acuta  (Strlimpell). — A  more 
or  less  diffuse  inflammation  of  the  cerebral  cortex  may  occur  {a)  in 
certain  toxic  conditions  due  to  gas  poisoning,  alcohol,  etc.;  (6)  as  a 
consequence  of  trauma;  (<?)  as  a  complication  of  such  acute  infec- 
tious diseases  as  tj^phoid  or  influenza;  or  {d)  with  local  suppura- 
tive processes,  particularly  those  of  the  middle  ear.    The  anatomical 


MENINGES,   EPENDYMA,  AND   BEAIN.  51 

features  of  the  process  are  analogous  to  those  which  occur  in  the 
Corel  in  acute  poliomyelitis. 

The  general  symptoms  are  those  which  accompany  all  severe  acute 
cerebrospinal  affections,  and  are  due  to  tension — headache,  somno- 
lence, vomiting,  fever,  delirium,  rapid  pulse,  and,  in  some  cases  of 
greater  severity,  choked  disk,  coma,  with  slow  pulse,  and  respiratory 
changes.  The  local  symptoms  are  variable  and  depend  upon  the 
situation  and  extent  of  the  lesion.  Paralyses  may  occur  or  irritative 
symptoms  of  an  epileptiform  character. 

Cerebral  abscess. — An  abscess  in  the  brain  is  rarely,  if  ever,  primary, 
although  occasional  instances  have  been  recorded  in  which,  even 
after  a  most  detailed  post-mortem  examination,  it  has  been  impos- 
sible to  attribute  its  presence  to  any  external  source  (Mills  and 
Spiller).  It  must  be  appreciated,  however,  that  the  lesion  may  be 
of  such  long  standing  that  the  original  focus  of  suppuration  else- 
where in  the  hodj  maj^  in  the  interval  have  completel}^  healed. 

It  is  usually  a  secondary  process,  and  the  three  most  important 
causal  factors  are:  (1)  TrauTrm,  which  accounts  for  50  per  cent  of 
the  cases.  We  have  seen  that  it  is  a  common  sequel  of  penetrating 
wounds  or  fractures  of  the  skull,  when  infected  material  of  one  sort 
or  another  has  been  inoculated  directly  into  the  brain  substance. 
Although  Bergmann  expressed  the  opinion  that  it  never  follows  a 
simple  contusion  of  the  head,  there  seem  to  be,  nevertheless,  authen- 
tic cases  in  which,  in  the  absence  of  fracture  or  external  evidence 
of  suppuration,  such  a  sequal  has  occurred  (Ehrenrooth).  In  all 
probability  the  blow  in  these  cases  has  led  to  a  rupture  of  cortical 
vessels  with  extravasation,  and  there  has  been  a  subsequent  hematog- 
enous infection  of  the  area  of  diminished  tissue  resistance  thus 
produced,  the  clot  proving  a  favorable  soil  for  bacterial  growth. 
It  has  already  been  shown  that,  in  similar  fashion,  a  local  suppura- 
tion may  occur  in  the  cranial  vault  after  a  simple  contusion;  this 
in  turn  may  lead  to  a  cerebral  abscess,  often  without  any  definite 
evidences  of  intervening  meningeal  infection.  Symptoms  of  cerebral 
abscess  may  not  appear  until  weeks  or,  indeed,  months  after  a  local 
wound  or  fracture  of  the  skull  has  healed.  This  is  especially  true 
of  cases  in  which  a  foreign  body,  such  as  a  bullet  or  a  broken  knife 
blade,  has  been  introduced  at  the  time  of  the  injury. 

(2)  In  pyemia.,  the  result  of  infected  wounds,  single  or  multiple 
abscesses  of  the  brain  can  occur,  but  owing  to  the  comparative  rarity 
of  this  condition  in  later  days  they  have  become  a  relatively  infre- 
quent autopsy  finding.  Metastatic  cerebral  abscesses,  however,  may 
accompan}^  ulcerative  endocarditis,  extensive  osteomyelitis  of  the 
long  bones,  etc.  Their  association,  particularly  with  suppurative 
pulmonic  diseases,  such  as  gangrene,  empyema,  or  bronchiectasis, 


52  WAR   SUEGERY   OF    THE    NERVOUS   SYSTEM. 

has  long  been  recognized.  In  100  cases  of  pulmonary  gangrene 
Nahter  found  8  with  cerebral  abscess.  Abscesses  may  follow  the 
specific  fevers,  influenza,  typhoid,  etc.,  even  without  the  association 
of  otitis  media. 

Tuberculous  abscesses — the  solitary  tubercle — are  probably  always 
metastatic.    They  will  be  considered  under  tumors. 

(3)  By  far  the  most  important  group  comprises  those  which  occur 
from  a  more  or  less  direct  extension  of  suppurative  disease  from  the 
TThiddle  ear^  mastoid  cells^  sphenoidal^  or  frontal  sinuses.  As  the 
result  of  the  long-standing  suppuration  in  one  of  these  cavities  a 
gradual  necrosis  of  their  thin  protecting  bony  shell  may  take  place. 
When  necrosis  has  occurred  any  sudden  flare-up  in  the  activity  of  the 
disease  may  lead  to  involvement  of  the  exposed  meninges,  and  later 
of  the  brain  itself,  particularly  if  there  be  any  tendency  to  retention 
of  the  secretions  due  to  a  cholesteatoma  or  exuberant  granulations. 
Even  with  no  intervening  meningitis,  the  infection  may  be  carried 
by  thrombosed  veins  or  along  Ijanph-spaces  directly  into  the  sub- 
cortical tissue. 

Focal  meningeal  abscesses  also  may  occur  without  a  spreading  men- 
ingitis; they  are  more  commonly  extradural,  though  pial  abscesses 
have  been  recorded  bj^  Randall,  Spiller,  and  others. 

The  several  m,odes  of  infection.,  therefore,  are:  (1)  By  direct  inoc- 
ulation; (2)  by  metastasis  through  the  blood  stream;  (3)  by  direct 
extension  of  the  suppurative  process  from  extracranial  cavities ;  (4) 
by  inoculation  through  infected  vessels  which  connect  with  an  extra- 
cranial or  extradural  suppuration.  In  the  latter  instance,  as  already 
stated,  there  may  be  no  visible  connection  whatever  between  the  origi- 
nal focus  and  the  subcortical  abscess — a  fact  which  often  enhances 
the  difficulty  of  the  surgical  problem.  It  has  been  suggested  in 
explanation  that  the  vascular  leptomeninges  and  cortex  offer  a 
greater  resistance  to  bacterial  infection  than  the  subcortical  nerve 
tissue,  to  which  the  infective  material  is  carried  b}'  the  capillary 
lymphatic  tubes  which  traverse  the  cortex  at  right  angles  to  the 
surface  and  are  in  direct  communication  with  the  subarachnoid 
space. 

Occurrence. — ^Abscesses  of  the  frontal  lobe  most  frequently  follow 
infection  of  the  frontal  sinuses ;  of  the  temporal  lobe  infection  in  the 
middle  ear  or  mastoid  antrum;  of  the  cerebellum  the  mastoid  cells 
themselves,  either  direct  or  through  an  intervening  sigmoid  sinus 
phlebitis. 

According  to  Grunert,  91  per  cent  follow  chronic  and  only  9  per 
cent  acute  otitis  media.  Partly  for  this  reason  adults  are  more  com- 
monly affected.  Holt,  in  his  report  of  five  cases  in  infants,  calls  at- 
tention to  its  presumed  rarity  in  the  young.     Oppenheim  has  re- 


MENINGES^   EPEKDYMA,   AND   BRAIN.  53 

ported  instances  of  abscess  foniiation  after  34  and  45  years  of  chronic 
otitis  media.  I  have  seen  cases  after  26  and  30  years.  In  9,000  au- 
topsies at  Guy's  Hospital,  Pitt  found  56  brain  abscesses,  18  of  them 
of  otitic  origin,  and  only  1  due  to  nasal  suppuration.  In  La  Fort 
and  Lehmann's  statistics  of  458  cases  of  abscess,  the  cerebrum  was 
involved  in  227;  the  cerebellum  in  113;  cerebrum  and  cerebellum  in 
11;  pons,  peduncles,  or  fourth  ventricle  in  7  cases.  Thus  we  see 
that  the  cerebrum  is  affected  more  than  twice  as  often  as  the  cerebel- 
lum. Cassirer  has  reported  15  cases  of  the  rarer  abscesses  which 
occur  in  the  brain  stem. 

I  have  seen  onh^  two  cases  of  frontal  lobe  abscess.  One  of  them 
followed  a  chronic  suppuration  of  the  frontal  sinus,  attributed  to  a 
rhinological  operation  for  the  removal  of  a  polyp — a  not  infrequent 
origin  of  sinus  disease.  The  other  was  an  acute  case  secondary  to  a 
bullet  wound,  the  missile  having  traversed  the  base  of  the  skull  and 
orbit,  opening  and  infecting  the  sinus.  Neither  of  these  cases  re- 
covered. In  his  study  of  the  cerebral  complications  of  sphenoidal 
sinus  disease,  St.  Clair  Thomson  records  but  one  case  of  abscess. 

Morbid  anatomy. — Abscesses  may  be  solitary  or  multiple;  diffuse 
or  definitely  circumscribed  by  a  capsule;  they  are  occasionally  multi- 
locular.  The  capsule  may  be  rapidly  formed  (Starr),  and  the  thick- 
ness of  its  wall  may  reach  several  millimeters.  Abscesses  of  otitic 
origin  may  be  bilateral  (Whitehead).  When  multiple  abscesses  occur 
they  are  usually  small ;  isolated  ones  sometimes  reach  such  a  size  that 
thej  occupy  the  greater  portion  of  a  lobe. 

The  character  of  the  pus  varies  greatly,  depending  upon  the  age  of 
the  abscess.  In  earl}^  cases  it  is  mixed  with  the  reddish  debris  of  dis- 
organized brain  matter;  in  the  later  cases  it  is  a^^t  to  have  a  greenish 
tint  and  a  peculiarly  disagreeable  odor.  The  bacteriological  examina- 
tion may  show  a  single  or  a  mixed  flora.  Though  staphylococci  or 
streptococci  are  the  ordinary  agents  of  infection,  the  pneumococcus 
and  still  more  unusual  forms  of  bacteria  may  be  met  with — strepto- 
thrix,  actinomycosis,  the  tj^phoid  baccillus    (McClintock),  etc. 

Even  when  an  abscess  is  directly  due  to  a  chronic  suppuration  of 
the  middle-ear  or  frontal  sinuses  it  may  have  no  apparent  connection 
with  the  original  side  of  disease ;  in  other  cases  there  may  be  a  local  or 
general  infection  of  the  meninges.  This  may  occur  secondary  to  rup- 
ture of  the  abscess  itself  into  the  subarchnoid  space — an  incident 
which  is  particularly  apt  to  follow  a  misdirected  operation.  Lossen 
has  shown  that  the  cerebellum  may  become  infected  by  extension  of 
suppuration  along  the  sheath  of  the  acusticus;  also  that  cerebellar 
abscesses  are  particularly  apt  to  be  complicated  by  sinus  thrombosis, 
meningeal  abscess,  or  meningitis. 


54  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

Symptoms. — When  secondary  to  a  chronic  otitis  media — and  cases 
of  this  sort  may  be  taken  as  typical  of  all — there  appear  in  sequence 
certain  new  symptoms  not  previously  observed.    For  example : 

A  patient  30  years  of  age  had  had,  since  an  attack  of  scarlet  fever  in  child- 
hood, a  chronic  discharge  from  the  right  ear.  He  had  had  several  acute 
exacerbations  of  the  local  disease,  none  of  them  serious  until  the  present  flare-up 
of  the  trouble.  Two  weeks  before  his  admission  there  had  been  an  increase 
in  the  discharge  and  some  granulations  were  removed  from  the  meatus.  Two 
days  later  he  complained  of  some  headache  and  nausea,  with  fever  and  chilly 
sensations  {initial  stage).  During  the  following  10  days  these  symptoms 
abated  somewhat,  but  did  not  entirely  disappear  {latent  stage).  Then,  with 
a  sudden  cessation  of  the  discharge  from  the  ear,  there  followed  a  severe  and 
constant  headnche,  vomiting,  a  pronounced  change  in  his  mental  activities,  with 
slowness  of  thought,  drowsiness,  irritability,  and  defective  memory.  The  pulse 
was  slow,  his  temperature  became  subnormal,  and  there  was  a  leukocytosis 
of  22,000  {rnanifest  stage).  There  were  no  focal  symptoms.  Percussion  over 
the  temporal  bone  on  the  side  of  the  disease  elicited  marked  tenderness.  An 
abscess  was  found  in  the  temporal  lobe,  with  no  evidence  of  meningeal  involve- 
ment. 

This  may  be  taken  as  a  fairly  typical  instance  of  the  clinical  pic- 
ture, showing  the  stages  of  the  disease  in  their  regular  succession. 
When  death  occurs  {terminal  stage)  it  is  accompanied  by  high  tem- 
perature and  the  usual  compression  phenomena  with  respiratory 
paralysis. 

The  clinical  history  is  of  paramount  importance  in  these  cases,  for 
there  are  no  absolutely  diagnostic  signs.  Other  than  the  symptoms 
thus  recorded  (the  cessation  of  discharge;  the  headache,  often  severe, 
rarely  absent;  vomiting;  perhaps  a  chill;  often,  though  not  alwaj^s, 
a  subnormal  temperature  and  slow  pulse;  drowsiness;  irritability; 
slow  cerebration;  delirium  and  loss  of  memory;  tenderness  to  per- 
cussion, etc.),  may  be  mentioned  the  following:  Facial  paralysis  may 
occur  and  be  homolateral  from  involvement  of  the  peripheral  nerve 
itself,  or  contralateral,  together  with  evidence  of  compression  of  the 
lower  precentral  area,  with  aphasia.  Occasionally  there  is  contrac- 
tion of  one  pupil,  followed  later  by  dilatation.  A  choked  disk  may 
develop.  Mental  symptoms  are  especially  pronounced  in  frontal  lobe 
abscesses.    Change  of  position  is  apt  to  lead  to  dizziness. 

If  the  acute  symptoms  subside,  if  encapsulation  take  place,  and  if 
the  abscess  be  situated  in  a  "  silent "  region,  it  may  remain  dormant 
for  years  and  only  be  disclosed  by  accident  at  a  post-mortem  examina- 
tion. Occasionally  when  the  lesion  is  situated  in  the  frontal  lobe 
and  has  led  to  mental  derangement,  the  victims  may  become  inmates 
of  an  asylum  and  be  regarded  as  chronically  insane. 

Even  in  the  presence  of  suspicious  symptoms  the  seat  of  the  lesion 
is  often  most  difficult  to  determine.  The  best  guide,  on  the  whole,  is 
the  situation  of  the  external  process  which  presumably  has  led  to  it. 
In  abscesses  of  the  temporal  lobe,  unless  they  have  involved  the  speech 


MENINGES,   EPENDYMA,  AND  BEAIN.  55 

mechanism  or  the  lower  motor  centers,  there  may  be  no  localizing 
symptoms.  Abscesses  of  the  cerebellum  are  particularly  difficult  to 
recognize,  although  suboccipital  pain,  vertigo,  dizziness,  nystagmus, 
or  cerebellar  ataxia  may  be  suggestive,  v.  Beck  regards  a  stiff  neck 
and  turning  of  the  head  toward  the  side  of  the  disease  as  important. 
Cerebellar  "  seizures,"  which  consist  of  sudden,  unexpected  attacks  of 
vertigo,  roaring  in  the  head,  relaxation  of  the  limbs,  and  falling  to  the 
ground  in  a  semiconscious  condition  (Dana),  may  be  helpful. 

Diagnosis. — In  the  acute  cases  one  must  distinguish  between 
abscess,  encephalitis,  meningitis,  ependymitis,  and  septic  sinus  throm- 
bosis. When  there  is  no  clear  sequence  of  events  such  as  have  been 
described,  a  certain  diagnosis  may  be  impossible.  The  chronic  cases 
are  not  infrequently  mistaken  for  tumors,  since  they  may  present  the 
same  underlying  pressure  phenomena. 

The  history  is  often  of  chief  importance,  for  a  neurological  exami- 
nation, particularly  in  the  absence  of  focalizing  symptoms,  is  most 
unsatisfactory  in  a  patient  sufficiently  ill  to  lead  to  a  suspicion  of 
abscess.  There  are  certain  points  which  are  helpful  in  differentiation. 
The  evidences  of  brain  pressure,  the  stupor,  the  slow  pulse,  respira- 
tory changes,  choked  disk  of  a  low  grade,  and  a  subnormal  tem- 
perature, are  apt  to  be  more  marked  in  abscess  than  in  meningitis  or 
encephalitis,  except  in  their  late  stages.  Cervical  rigiditj^  and  Ker- 
nig's  sign  are  more  characteristic  of  meningitis  than  abscess,  and  the 
former  usually  has  a  higher  leukocyte  count  ( Starr. )  Sinus  throm- 
bosis has  a  characteristically  irregular  fever;  there  is  tenderness  at 
the  tip  of  the  mastoid  and  the  jugular;  exophthalmos  follows  when 
the  cavernous  sinus  is  involved.  There  is  no  history  of  suppuration 
in  the  cases  of  acute  hj^drocephalus  following  ependymal  inflamma- 
tions, and  here  choked  disk  appears  early  and  reaches  a  high  grade. 
The  differentiation  between  abscess  and  meningitis  may  at  times 
be  made  by  an  examination  of  the  fluid  obtained  by  a  lumbar  punc- 
ture. The  cerebrospinal  fluid,  even  if  bacteria  are  absent,  shows  an 
increased  number  of  leukocytes,  both  in  tuberculous  and  in  the  early 
stages  of  ordinary  septic  meningitis.  This  is  not  true  of  abscess,  unless 
it  be  complicated  by  meningitis.  Allan  Starr  regards  this  as  a  valu- 
able aid.  Fuchs  and  Rosenthal  have  found  as  high  as  952  cells  in 
tuberculous  meningitis  and  100  in  general  meningitis;  whereas  there 
should  normally  be  but  one  or  two  in  a  centrifugated  specimen 
of  5  cc.  Neumann  and  Grunert  found  no  bacteria  in  the  cerebro- 
spinal fluid.  Indeed,  in  many  abscesses  of  long  standing  cultures 
from  the  abscess  itself  prove  sterile.  There  is,  I  think,  always  a  cer- 
tain element  of  danger  in  a  lumbar  puncture,  since  the  altered  condi- 
tions of  tension  may  lead  to  a  rupture  of  the  abscess,  particularly  if 
it  be  cerebellar;  only  a  small  amount  of  fluid,  therefore,  should  be 
withdrawn. 


56  WAE    SURGERY   OF   THE    NERVOUS   SYSTEM. 

There  are  two  complications  of  otitis  media  which  I  have  found  to 
offer  especial  difficulties  of  diagnosis.  In  one  of  them  symptoms- 
closely  resembling  intracranial  extension  of  disease  may  be  produced 
by  a  reflex  disturbance  through  the  trigeminal  nerve.  These  patients 
show  no  rise  in  temperature ;  but  great  tenderness,  headache,  nausea, 
and  even  vomiting  may  occur.  The  tenderness,  however,  is  superfi- 
cial and  conforms  with  tlie  trigeminal  sensory  skin  field;  even  the 
hair  can  not  be  touched  without  discomfort.  I  have  seen  several  cases 
of  this  sort  recover  without  operation,  and  they  may  possibly  repre- 
sent a  mild  degree  of  dural  involvement.  The  other  complication, 
due  to  an  acute  serous  meningitis  (not,  so  far  as  is  known,  of  bacterial 
origin)  is  still  more  common  and  may  closely  simulate  abscess.  In 
these  cases  a  lumbar  puncture  or  a  decompressive  craniectomy  with 
evacuation  of  the  fluid  proves  curative;  should,  therefore,  a  super- 
abundance of  clear  fluid  be  disclosed  in  an  exploratory  operation  for 
abscess  it  is  wise  not  to  be  too  persistent  in  the  search  for  a  pocket 
of  pus. 

The  j)rognos/8  without  operation  is  absolutely  bad :  with  operation 
it  is  not  brilliant.  Even  in  experienced  hands  the  mortality  remains 
about  60  per  cent;  for  an  abscess  may  not  be  found,  and  if  it  is 
found  and  evacuated  there  may  arise  unavoidable  and  often  fatal 
complications — a  second  abscess  due  to  inefficient  drainage,  a  fungus 
cerebri,  purulent  meningitis,  septic  sinus  thrombosis,  pj^emia,  etc. 

Treatment. — Most  important  of  all  therapeutic  measures  is  pro- 
phjdaxis.  The  fact  that  cerebral  abscess  is  less  commonly  observed 
than  formerly  may  be  accounted  for  by  the  greater  promptitude  and 
greater  skill  shown  in  the  treatment  of  those  diseases  whose  neglect 
leads  to  it.  Owing  to  Macewen's  book,  which  has  had  a  deserved 
popularity  among  practitioners  in  general,  rhinologists  and  otologists 
are  alive  to  the  fact  that  early  radical  treatment  of  suppurating 
processes,  while  they  remain  extracranial,  is  the  best  treatment  for 
these  intracranial  complications.  Probably  more  than  one-half  of  all 
cases  are  .'-ecoidary  to  suppuration  in  the  otitic  and  rhinitic  cavities, 
and  if  they  become  involved  during  the  course  of  such  infectious 
diseases  as  pneumonia,  influenza,  scarlet  fever,  typhoid,  etc.,  when 
patients  are  seriously  ill  and  unable  to  call  attention  to  local  dis- 
comforts the  infection  may  easily  be  overlooked. 

When  an  abscess  has  formed  in  spite  of  all  care,  the  condition  is 
serious ;  a  critical  operation  must  be  resorted  to ;  and  even  with  our 
modern  methods  the  mortality  remains  high.  Up  to  1884:  only  55 
cases  of  operation  had  been  reported  (Korner)  and  Bergmann,  in 
1889,  could  find  a  record  of  only  8  recoveries.  Since  Macewen's' 
treatise  (1893),  however,  the  operations  have  so  multiplied  that  they 
cease  to  be  regarded  as  rarities.  By  1898  there  were  records  of  60 
successful  operations  upon  temporal  and  12  upon  cerebellar  abscesses 


MENINGES^   EPENDYMA,   AND   BRAIN.  5^ 

(Mai'sch).  Unfortunately,  however,  these  operations  still  continue 
to  be  conducted  as  a  last  resort  in  the  "  manifest "  or  even  near  the 
"  terminal "  stage  of  the  disease.  They  should,  on  the  other  hand,  be 
undertaken  early,  without  waiting  for  unequivocal  symptoms,  for, 
as  Korner  says,  "Auf  mehr  Zeichen  warten,  heisst  auf  mehr  Leichen 
warten." 

Method  of  iwocedure. — It  is  Macewen's  opinion  that  in  the  otitic 
cases  it  is  wise,  when  there  is  a  question  of  cerebral  abscess,  to  open 
first  of  all  through  the  squamous  portion  of  the  temporal  bone. 
Otologists,  as  a  rule,  owing  to  their  greater  familiarity  with  the 
method  of  approaching  the  dura  through  the  mastoid  region  and  then 
through  the  tegmen  tympani,  favors  this  posterior  route.  There  is 
much  to  be  said  for  both  views.  The  surgeon  who  is  particularly 
familiar  with  cranial  operations,  in  case  there  is  some  doubt  as  to  the 
nature  of  the  intracranial  complication,  might  prefer,  as  aprimar}^ 
measure,  to  open  the  skull  through  the  squamous  portion  of  the 
temporal  bone,  in  order  to  expose  the  dura  and,  if  necessary,  the 
temporal  lobe  in  the  middle  cranial  fossa ;  for  should  the  exploratory 
intracranial  operation  be  conducted  through  the  diseased  ear,  the 
risk  of  producing  infection  would  be  greatly  enhanced.  On  the  other 
hand,  the  otologist,  after  cleaning  out  the  mastoid  cqUs,  the  infected 
antrum,  and  middle  ear,  is  inclined  to  wait  for  a  day  or  two  to  see 
Avhether  the  suspicious  intracranial  symptoms  do  not  subside. 

I  am  not  convinced  which  of  these  methods  is  the  better,  and  have 
followed  at  times  one^  at  times  the  other;  judgment  must  depend 
upon  the  individual  case.  .With  experience  it  is  a  simple  matter  to 
explore  intracranially  the  roof  of  the  petrous  bone,  the  dura  over- 
lying it,  and,  if  necessary,  the  temporal  lobe  without  risk.  I  prefer 
to  do  this  by  the  muscle-splitting  operation.  In  case  nothing  is  found 
this  wound  may  then  be  closed — a  measure  which  would  perhaps  be 
unsafe  if  the  infected  field  had  been  primaril}^  opened  up.  Particu- 
larly in  the  "  initial "  or  "  latent "  stages,  when  diagnosis  may  be  in 
doubt,  the  primary  mastoid  operation  is  advisable,  leaving  an  open 
Avound.  If  the  suspicious  symptoms  should  continue  the  opening  may 
be  so  enlarged  and  deepened  as  to  remove  a  part  of  the  tegmen 
tympani;  possibly  an  extradural  focus  maj^  be  disclosed,  or  if  not, 
the  temporal  lobe  may  be  explored  with  a  hollow  needle  from  below. 
Many  successful  operations  performed  by  this  route  have  been  re- 
ported, most  of  them  by  otologists.  When  there  is  a  question  of 
involvement  of  the  cerebellum  I  think  there  is  no  doubt  but  that  this 
latter  method  is  preferable;  namelj^,  to  clean  out  the  mastoid  cells, 
antrum,  and  ear  first,  and  at  the  same  time  to  investigate  the  sigmoid 
sinus.  Unless  symptoms  are  urgent  the  cerebellar  exploration  may 
be  deferred  for  a  day  or  two. 


58  WAR  SURGERY   OF    THE    NERVOUS   SYSTEM. 

When  an  abscess  has  been  found  it  should  be  treated  like  an  abscess 
elsewhere,  with  free  incision  and  drainage.  It  is,  however,  often 
difficult  to  accomplish  this,  owing  to  the  fact  that  about  the  edges  of 
the  incision  in  the  brain  the  cerebral  substance  becomes  edematous, 
swells,  and  tends  to  occlude  the  opening  and  retain  the  discharges. 
Furthermore,  unless  meningeal  adhesions  have  formed — and  they  are 
unusual — there  is  a  likelihood  of  meningeal  infection  as  a  result  of 
cerebrospinal  fluid  leakage  alongside  of  the  draining  abscess.  While 
the  brain  harbors  an  abscess  it  is  tense  and  the  exposed  cortex  tends 
to  protrude  through  the  opening  which  has  been  made  in  the  dura; 
after  the  abscess  has  been  evacuated  this  tension  subsides  and  the 
cerebrospinal  space  once  more  opens  up  and  can  be  reached  b}^  the 
infection. 

When,  however,  adhesions  are  present  and  serve  to  bind  together 
the  dura,  arachnoid,  pia,  and  cortex,  the  approach  to  the  abscess  may 
be  conducted  with  a  minimum  of  risk.  Owing  to  the  fact  that  an 
abscess  may  assume  a  mushroomlike  shape  with  a  narrow  stalk  at  the 
original  site  of  infection,  it  may  often  be  opened  through  this  stalk 
without  doing  further  damage  to  the  cortex  than  has  already  oc- 
curred from  the  disease  (Ballance).  Preysing's  figures  well  illustrate 
this  type  of  abscess,  and  such  conditions  give  a  particularly  favorable 
operative  prognosis. 

In  exploring  for  an  abscess  it  is  essential  to  use  a  proper  hollow 
needle  with  a  blunt  end  and  with  one  or  more  openings,  which  should 
be  on  the  side.  The  brain  should  be  freely  incised  on  a  director 
introduced  to  the  same  point  at  which  the  pocket  of  pus  may  chance 
to  have  been  entered.  It  is  well  to  avoid  irrigation  of  an  abscess, 
though  this  is  a  procedure  commonly  followed.  Free  drainage  is  the 
essential  thing,  and  in  the  absence  of  further  symptoms  the  gauze 
should  remain  long  undisturbed.  The  patient  should  lie  with  the 
opening  downward. 

A  complication  which  may  arise  during  the  operation,  especially 
when  conducted  in  the  "  manifest  stage  "  of  the  disease,  is  respiratory 
failure  from  the  additional  burden  of  the  anesthetic  on  an  already 
embarrassed  respiratory  center.  It  is  essential  in  these  operations, 
therefore,  that  an  artificial  respiration  apparatus  be  at  hand,  for 
when  put  in  use  it  is  possible  to  continue  the  operation,  and  if  an 
abscess  should  be  found  and  evacuated  the  spontaneous  resumption 
of  respiration  with  recovery  is  possible.  Many  remarkable  cases  of 
this  primary  respiratory  failure  with  continuance  of  cardiac  activity 
have  been  reported.  I  have  had  one  patient  in  whom,  though  the 
operation  was  completed  under  artificial  respiration  and  an  abscess 
was  fo:ind.  there  was  no  resumption  of  spontaneous  breathing, 
though  the  heart  continued  to  beat  for  23  hours ;  on  another  occasion 
a  patient  was  saved. 


MENINGES,    EPENDYMA,   AND    BRAIN.  59 

CONCUSSION,  CONTUSION,  AND  COMPRESSION. 

These  terms,  of  time-honored  usage,  are  often  loosely  employed 
and  with  but  faint  understanding,  not  only  of  the  pathological 
lesions  underlying  the  conditions  so  designated,  but  even  less  of  the 
physiological  phenomena  they  evoke.  They  deserve,  nevertheless,  to 
be  retained  and,  as  is  the  custom,  they  will  be  considered  together. 

The  three  conditions  shade  so  imperceptibly  into  one  another 
that  it  is  often  difficult  to  determine  where  true  concussion  ends  and 
symptoms  of  contusion  begin;  and  likewise  where  symjDtoms  of  con- 
tusion end  and  those  of  compression  begin.  Indeed,  in  the  minds 
of  many,  concussion  is  but  a  grade  of  contusion  and,  furthermore, 
cerebral  contusion  is  impossible  without  some  degree  of  compression, 
whether  from  hemorrhage  or  edema,  provided  the  skull  is  closed 
and  the  cranial  bones  remain  intact.  A  single  illustration  will  serve 
to  show  how  these  states  may  overlap : 

A  workiugman  fell  from  a  scaffold  on  his  head.  "  Concussion  "  was  evidenced 
by  the  immediate  loss  of  consciousness.  His  failure  to  recover  from  this  state 
in  the  course  of  a  few  hours  raised  a  suspicion  of  "  contusion  "  and  free  blood 
would  have  been  found  in  the  arachnoid  space.  He  died  in  a  short  time  with 
symptoms  of  "  compression."  At  autopsy  there  was  found  a  laceration  of  the 
orbital  surface  of  the  right  frontal  lobe  with  a  large  extravasation  which  had 
forced  its  way  into  the  brain  substance  alongside  of  the  basal  ganglia. 

Concussion  and  contusion  are  the  effects  soleh^  of  traumatism.  The 
symptoms  of  compression  likewise  follow^  an  injury  vrhen,  as  in  the 
case  just  cited,  it  leads  to  intracranial  hemorrhage  or  to  sw^elling  of 
the  brain  within  the  closed  skull.  In  its  varying  grades,  however, 
compression  is  even  more  often  the  result  (1)  of  spontaneous  hem- 
orrhage, as  in  apoplexy;  or  (2)  of  edema  originating  in  other  than 
traumatic. sources,  such  as  nephritis,  or  disturbed  circulatory  condi- 
tions of  the  cerebrospinal  fluid  the  result  of  ventricular  h37^drops, 
or  meningeal  inflammation;  or  (3)  of  the  foreign-body  effects  of 
an  abscess  or  new  growth  within  the  cranial  chamber. 

Concussion  {Commotio  cerebri;  Mrnerschiltterung,  etc.). — An  indi- 
vidual may  be  momentaril}''  stunned  by  a  slight  blow  upon  the  head. 
No  subsequent  ill  effects  need  follow.  A  more  serious  blow  may  lead 
to  an  actual  temporary  loss  of  consciousness,  on  recovery  from  which 
certain  sensations  of  weakness,  dizziness,  or  headache  may  persist 
for  a  time.  A  still  more  violent  blow  may  produce  unconsciousness, 
even  coma,  of  longer  duration,  and  may  leave  the  victim  mentally 
disturbed  for  hours  or  days,  with  loss  of  memory  of  the  events  con- 
nected with  the  injury;  with  headache,  possibly  nausea  and  vomit- 
ing; with  ataxia  and  dizziness,  especially  when  an  upright  posture 
has  been  assumed;  and  perhaps  even  with  medullary  symptoms, 
shown  by  slow  pulse  or  respiratory  changes.    All  of  these  symptoms 


60  WAR   SUEGEEY   OF   THE    NERVOUS   SYSTEM. 

may  endure  for  days  and,  in  fact,  often  may  leave  the  patient  a 
permanent  victim  of  post-traumatic  neuroses. 

Morbid  anatomy. — To  what  are  these  symptoms  due?  Though 
experimentalists  and  pathologists  have  long  endeavored  to  answer 
this  question,  they  have  not  done  so  to  the  satisfaction  of  all.  Pa- 
tients in  whom  serious  conditions  of  concussion  have  led  to  death 
may  shoAv  at  autops}^  no  cerebral  lesion  whatsoever.  They  may  at 
other  times  show  certain  foci  of  extravasation  scattered  throughout 
the  brain — in  other  words,  microscopic  evidences  of  contusion.  These 
lesions  and  the  symptoms  which  they  produce  bear  no  definite  rela- 
tion to  any  cranial  injury.  The  slmll  may  or  may  not  have  been 
broken  at  the  time  of  the  injury  and,  indeed,  some  of  the  most  serious 
cases  of  concussion  are  unaccompanied  by  fracture.  It  is  true  that 
most  injuries  which  suffice  to  cause  a  fracture  are  accompanied  by 
symptoms  of  concussion  or  contusion,  though  this  is  not  invariable. 
Local  depressed  fractures,  for  example,  can  occur  without  even  a 
momentary  loss  of  consciousness,  this  being  the  one  cardinal  feature 
of  concussion. 

The  view  is  held  by  some  that  a  simple  jar  of  the  brain  may  so 
disturb  the  molecular  integrity  of  the  nerve  cells  as  to  lead  to  uncon- 
sciousness, even  to  coma  and  death,  and  yet  produce  no  lesion  which 
is  recognizable,  even  by  a  most  thorough  histological  studj''.  As 
shown  by  Koch  and  Filehne,  and  later  by  Witkowski,  symptoms 
which  are  compar;ibie  to  those  of  concussion  as  it  is  seen  in  man 
may  be  elicited  by  rapidl}'  repeated  blows  upon  the  cranium  of  an 
animal — unconsciousness,  slow  pulse,  relaxation  of  the  muscles,  in- 
sensibility to  sensory  stimulation,  etc.  Even  should  these  symptoms 
be  severe  enough  to  result  in  a  fatality,  a  post-mortem  examination 
may  show  nothing  more  than  some  evidence  hj  hyperemia  of  the 
brain  and  meninges.  Fischer  believed  that  the  symptoms  are  occa- 
sioned by  a  reflex  parah^sis  of  the  vasomotor  center,  which  leads  to  a 
sudden  failure  in  blood  pressure  analogous  to  that  which  occurs  in 
shock. 

On  the  other  hand,  patients  in  whom  symptoms  of  concussion  have 
not  been  severe  may  die  from  the  effects  of  concomitant  injuries,  and, 
contrary  to  expectation,  the  brain  may  be  found  at  autopsy  more  or 
less  lacerated  and  containing  scattered  foci  of  extravasation  due  to 
capillary  hem^orrhages.  When  such  extravasations  occur  in  the  neigh- 
borhood of  the  pons  or  medulla  they  are  commonly  fatal.  Such  find- 
ings are  naturally  classified  as  contusion. 

Upon  these  different  view^s  two  schools  have  grown  up:  (1)  Those 
believing,  with  the  late  von  Bergmann,  that  simple  concussion  may 
exist  without  extravasation,  and  (2)  those  agreeing  with  Kocher  in 
regarding  concussion  as  the  result  of  minute  contusions  scattered 


IVlF.NriNGES,    EPENDYMA,    AND   BEAIN.  61 

throughout  the  brain  in  consequence  of  the  transmitted  effects  of  the 
blow. 

Symptoms. — Distnrljances  of  consciousness  are  essential  to  con- 
cussion. The  victim  may  be  in  a  simple  lethargic  state  from  which 
he  can  be  aroused,  or  in  the  deep  sleep  of  a  drunken  person.  As 
unconsciousness  passes  away  general  evidences  of  cerebral  disturb- 
ance appear.  There  is  headache,  vertigo,  often  nausea  and  vomiting, 
possibly  convulsions,  often  a  sul)normal  temperature,  at  time  changes 
in  the  cardiac  and  respiratory  rates,  and  almost  always  more  or  less 
loss  of  memory  of  the  events  incidental  to  the  injury.  In  addition  to 
these  general  symptoms,  inasmuch  as  many  cases  of  simple  con- 
cussion are  complicated  bj^  symptoms  due  to  laceration  of  the  brain 
and  extravasation  of  blood,  focal  s3nnptoms  may  be  present. 

As  indicated  in  the  introductory  paragraphs,  the  severity  and  the 
duration  of  the  sjanptoms  of  concussion  are  most  variable.  In  a  mild 
case  recovery  occurs  after  a  brief  interval.  In  more  severe  cases, 
when  consciousness  has  been  restored,  the  patient  may  perform  more 
or  less  automatic  acts  of  which  he  subsequently  has  little  memory, 
and  he  may  be  left  for  a  time  incapacitated,  both  physically  and 
mentally.  In  still  more  severe  cases  profound  unconsciousness  may 
endure  for  a  considerable  time,  during  which  the  reaction  to  external 
stimuli  is  abolished,  such  as  failure  of  the  conjunctival  reflexes.  The 
pupils  in  the  early  stages  are  apt  to  be  contracted.  There  may  be 
involuntary  passage  of  urine  and  feces.  If  this  condition  persists 
for  some  hours  or  da.js  it  is  probable  that,  in  addition  to  the  concus- 
sion, more  serious  lesions  have  been  produced. 

In  some  instances  of  concussion  a  period  of  excitation  may  follow 
the  period  of  depression  of  the  vital  functions.  The  patient  may  be- 
come violent,  irritational,  and  may  have  to  be  forcibly  confined.  An 
early  rise  in  temperature  has  been  observed  in  simple  cases  of  con- 
cussion. In  severe  cases  it  is  not  unusual  for  the  ten  days  or  two 
weeks  of  convalescence  to  be  attended  by  a  subnormal  temperature 
and  slowed  pulse. 

Prognosis. — Any  case  of  cranial  injury  which  results  in  concussion 
must  be  given  a  guarded  prognosis,  not  only  as  to  the  immediate  out- 
come, but  also  as  to  the  final  restoration  of  normal  cerebral  activity. 
Owing  to  edema  alone,  symptoms  of  compression  may  supervene  in 
what  might  have  been  considered  a  simple  case  of  concussion;  con- 
valescence may  be  indefinitely  protracted,  owing  to  the  headache, 
mental  depression,  etc.,  Avhich  characterize  the  familiar  post- 
traumatic neuroses  that  oftentimes  follow  such  injuries. 

Treatment. — A  careful,  examination  of  the  head  should  be  made 
in  view  of  a  possible  fracture.  In  questionable  cases  it  is  wise  to 
shave  the  scalp.  Should  there  be  evidence  of  failure  in  arterial  ten- 
sion, due  to  the  temporary  upsetting  of  the  vasomotor  center,  efforts 


62  WAR    SUEGEEY   OP   THE    NEEVOUS    SYSTEM. 

should  be  made  to  improve  the  circulation  by  cardiac  stimulants  or, 
better,  by  measures  directed  toward  supporting  the  relaxed  peripheral 
vessels,  particularly  those  of  the  splanchnic  field,  as  by  bandaging 
the  extremities  or  by  pressure  on  the  abdomen.  The  patient  should 
be  kept  quiet,  warm,  and  his  head  low.  An  ice  cap  should  be  applied. 
Atropin  is  said  to  be  a  desirable  drug. 

In  case  the  early  symptoms  have  been  severe,  it  is  essential  that 
enforced  rest  and  quiet  should  be  continued  for  a  period  of  from  10 
days  to  two  weeks,  with  daily  free  evacuation  of  the  bowels,  an  ice 
cap,  and  a  light  diet.  Should  a  suspicion  of  further  complications 
arise  and  especially  should  pressure  symptoms  supervene  at  any 
time,  a  decompressive  operation  is  indicated.  It  may  be  wise  to  pre- 
cede this  by  a  lumbar  puncture,  which  will  indicate  whether  there 
has  been  an  extravasation  of  blood  or  whether  the  symptoms  are 
simply  due  to  an  excess  of  fluid  from  edema.  In  the  latter  case  the 
puncture  alone  may  often  serve  to  alleviate  them. 

Contusion. — Concussion,  as  has  been  said,  may  be  regarded  as 
nothing  more  than  a  low^  form  of  contusion,  even  though  there  may 
be  no  demonstrable  evidence  of  bruising.  In  case  these  contusions 
result  in  extravasation,  macroscopical  evidences  of  hemorrhage  may 
be  present,  and  from  these  small  foci  of  extravasation  we  may  pass 
through  all  grades  of  contusion  up  to  actual  laceration  of  areas  of  the 
brain.  Post-mortem  examinations  after  traumatic  death  occasionlly 
reveal  unsuspected  lacerations  of  wide  extent,  even  when  symptoms 
of  concussion  have  been  relatively  slight.  Cases  of  this  sort  argue 
somewhat  in  favor  of  a  clinical  differentiation  between  concussion 
and  contusion. 

Contusions  with  or  without  laceration,  as  pointed  out  by  Duret,  are 
most  apt  to  occur  at  the  tips  of  the  temporal  lobe  and  base  of  the 
frontal  lobes.  These  lacerations  are  a  frequent  accompaniment  of 
basal  fractures,  for  the  same  injury  which  suffices  to  produce  the 
laceration  is  likely,  at  the  same  time,  to  cause  a  bursting  fracture  of 
the  skull.  Contusions  often  occur  at  that  part  of  the  brain  opposite 
to  the  point  of  external  traumatic  impact,  and  consequently  these 
cerebral  lesions  afford  a  better  illustration  of  the  effects  of  injury  by 
contrecoup  than  do  those  of  the  skull  itself. 

Course. — What  has  been  said  of  concussion  applies  likewise  to  the 
symptomatology,  diagnosis,  and  prognosis  of  contusions  and  lacera- 
tions of  the  brain,  though  in  them  the  immediate  symptoms  are  usu- 
ally much  more  pronounced.  The  period  of  "concussion"  is  longer 
and  certain  evidences  of  compression  almost  always  supervene :  early 
when  due  to  hemorrhage,  later  when  brought  about  by  contusion 
edema. 

Extravasations  from  the  injured  vessels  vary  greatly  in  number, 
in  situation,  and  in  extent.    They  may  be  intracerebral  and  multiple, 


MENINGES,  EPENDYMA,   AND  BKAIN.  63 

and  in  case  they  involve  important  centers  may  be  rapidly  fatal  with- 
out giving-  symptoms  of  compression. 

Most  forms  of  laceration,  however,  primarily  affect  the  cortex, 
particularly  at  the  base;  consequently  the  presence  of  blood  in  the 
subarachnoid  space  is  almost  invariable,  and  as  this  can  easily  be 
determined  by  a  lumbar  puncture,  this  measure  should  become,  for 
diagnostic  purposes,  a  routine  procedure  in  all  suspicious  cases.  At 
times  the  extravasation  which  follows  even  a  small  area  of  contusion 
may  be  large  and  intracerebral,  leading  to  death  from  compression. 

Not  only  are  the  symptoms  of  contusion  more  pronounced  and 
more  enduring  than  are  those  of  simple  concussion,  but  convalescence 
as  well  is  more  protracted  and  patients  are  almost  certain  to  be 
troubled  for  some  time  with  symptoms  of  headache,  nervousness,  ir- 
ritability, and  mental  depression. 

Treatment. — As  in  concussion,  enforced  rest  is  essential  and  should 
be  persisted  in  for  at  least  a  period  of  two  or  three  weeks.  These 
patients  amost  invariably  reach  a  certain  stage  of  well-being  in  which 
they  wish  to  escape  from  confinement  and  resume  their  work  long  be- 
fore they  are  fit  to  do  so.  They  are  almost  always  discharged  from 
hospital  care  earlier  than  the  nature  of  the  lesion  justifies.  Until 
there  is  a  complete  cessation  of  headache ;  until  the  pulse  rate,  which 
is  almost  always  slowed  after  such  a  lesion,  reaches  the  normal ;  until 
there  is  a  complete  disappearance  of  evidence  of  intracranial  pressure 
shown  by  some  stasis  in  the  eye  grounds,  they  must  be  kept  quiet,  on 
a  light  diet,  and  recumbent. 

Many  of  the  more  severe  symptoms  accompanying  contusion  may 
be  avoided  by  properly  conducted  surgical  procedures.  Lacerations 
of  the  temporal  lobe  which  have  led  to  local  intermeningeal  extrava- 
sations may  be  greatly  benefited  by  operative  measures.  When  there 
is  doubt  about  the  condition  an  exploration  through  the  split  tem- 
poral muscle,  with  removal  of  bone,  will  determine  whether  or  not 
there  is  any  lesion  present;  and  often  the  period  of  post-traumatic 
edema  may  be  shortened  and  the  symptoms  which  accompany  it  less- 
ened by  such  a  measure.  It  is  preferable  needlessly  to  operate  on 
some  borderline  cases  than  to  neglect  those  which  might  thus  be 
benefited. 

Compression. — With  the  exception  of  a  small  amount  of  cerebro- 
spinal fluid,  the  brain,  including,  of  course,  its  meshwork  of  blood 
vessels,  normally  fills  the  cranial  chamber.  The  cerebral  nervous 
tissue  itself  is  as  incompressible  as  water.  In  so  far,  however,  as  the 
brain  is  a  vascular  organ,  it  may  be  made  smaller  by  having  some  of 
its  blood  supply  squeezed  out  through  pressure.  Thus  a  foreign  body 
experimentally  introduced  into  the  cranial  chamber  makes  room  for 
itself  by  a  local  emptying  of  vessels  in  the  neighborhood,  leading  to 
the  so-called  local  increase  in  intracranial  tension.    The  compression 


64  WAR   SUEGEEY   OF   THE    NERVOUS   SYSTEM. 

effects  of  such  a  local  disturbance  diminish  with  the  distance  from  the 
primary  seat  of  pressure,  and  only  in  case  they  are  of  high  degree  are 
they  felt  throughout  the  entire  chamber.  On  the  other  hand,  should 
fluid  under  pressure  be  let  into  the  cranium  in  such  a  way  that  it 
distributes  itself  in  the  subdural  space  through  the  entire  chamber, 
leading  to  an  equable  pressure  or  tension  in  all  parts,  we  may  speak 
of  the  condition  as  one  of  general  increase  in  intracranial  tension. 
Compression  which  results  from  processes  of  these  two  sorts  must  be 
differentiated.  No  form  of  encroachment,  however,  on  the  intra- 
cranial space  fails  to  affect  the  cerebral  circulation,  and  it  is  this, 
circulatory  disturbance  which  plays  the  chief  role  in  eliciting  the 
phenomena  of  compression. 

There  are  exact  clinical  counterparts  of  these  experimentally  in- 
duced conditions.  Thus,  a  tumor  or  abscess,  a  focal  edema,  a  vascu- 
lar extravasation,  whether  it  be  outside  the  dura  or  in  the  brain  sub- 
stance itself,  an  operation  such  as  the  Gasserian  ganglion  operation 
w^hich  necessitates  ele^  ation  and  compression  of  a  lobe  of  the  brain, 
etc. — any  one  of  these  things  may  lead  to  a  local  increase  of  tension, 
the  pressure  effects  of  which  diminish  in  proportion  to  the  distance 
from  the  local  process.  On  the  other  hand,  in  meningitis,  in  hydro- 
cephalus, in  general  edema,  in  widespread  basal  hemorrhages,  or  in 
the  congestion  secondary  to  extensive  sinus  thrombosis,  the  increase 
of  tension  is  more  general  and  its  effects  are  exerted  in  equal  degree 
against  all  parts  of  the  cerebrum. 

Compression,  therefore,  may  occur  in  a  variety  of  ways;  either 
through  the  accession  of  some  abnormal  substance,  or  through  an 
abnormal  accumulation  of  some  substance  already  present.  Thus,  a 
new  growth  or  an  abscess  may  produce  compression,  provided  the 
space,  which  the  brain  normally  should  occupy,  is  encroached  upon ; 
-either  of  them  may,  however,  be  present  and  elicit  no  symptoms  of 
compression  in  case  they  destroy  the  brain  as  they  progress.  Again, 
an  increase  in  the  normal  amount  of  cerebrospinal  fluid  may  lead 
to  symptoms  of  compression  in  case  the  fluid  is  more  rapidly  formed 
than  usual  or,  as  in  obstructive  hydrocephalus,  in  case  it  finds  unusual 
difficulty  in  escaping  from  the  cranial  chamber.  Edema,  the  result 
•of  injuries  or  of  chemical  disturbances  in  the  body  fluids  brought 
about  by  nephritis,  may  likewise  be  the  source  of  compression. 

The  symptoms,  however,  in  many  of  these  conditions,  owing  to  the 
iact  that  the  cerebral  lesions  progress  slowly,  are  not  exactly  com- 
parable with  the  symptoms  which  have  been  produced  experiment- 
ally ;  for  experimental  studies  have  been  devoted  largely  to  the  con- 
sideration of  those  phenomena  which  follow  an  acute  increase  of 
intracranial  tension.  Consequently  the  laboratorj^  observations  are 
more  directly  comparable  with  clinical  cases  of  acute  compression, 


MENINGES,   EPENDYMA,  AND  BRAIN.  65 

such  as  occur  in  hemorrhage,  rather  than  with  cases  of  slowly  pro- 
gressive increase  in  tension,  due,  for  example,  to  tumor. 

Physiological  effects  of  acute  compression. — Galen,  Boerhaave,  Hal- 
ler,  Magendie,  and  many  others  recorded  observations  on  the  sympto- 
matic response  to  pressure  against  the  brain.  In  recent  time,  more 
complete  studies  have  been  made  by  Leyden,  Pagenstecher  and 
Duret,  by  Bergmann,  Naunyn  and  Schreiber,  by  Spencer  and  Hors- 
ley,  Leonard  Hill,  Kocher,  the  writer,  and  many  others.  A  few  of 
the  more  important  factors  which  have  been  brought  out  in  the 
laboratory  may  be  mentioned,  in  order  that  we  may  better  understand 
the  physiological  responses  to  compression  which  we  encounter  in 
clinical  cases. 

It  has  been  emphasized  by  some  that  the  first  effect  of  any  en- 
croachment on  the  intracranial  space  is  to  drive  out  of  the  chamber 
the  small  amount  of  cerebrospinal  fluid  which  is  normally  present. 
A  further  encroachment  can  only  occur  by  crowding  out  of  the  blood- 
vessels a  certain  amount  of  their  content,  and  inasmuch  as  the  tension 
in  the  cerebral  veins  is  lower  than  in  the  other  vascular  branches, 
these  vessels  are  the  first  to  suffer.  Venous  stasis,  therefore,  is  one 
of  the  first  consequences  of  the  pressure.  A  further  augmentation  of 
the  compressing  force,  with  still  greater  encroachment  on  the  intra- 
cranial space,  soon  brings  the  pressure  exerted  against  the  brain  up 
to  the  level  of  the  pressure  in  the  capillaries  and  even  to  the  arterial 
tension,  and,  needless  to  say,  cerebral  anemia  results,  with  early  and 
irrecoverable  loss  of  function  in  those  parts  of  the  brain  whose  circu- 
lation has  thus  been  completely  shut  off  for  any  considerable  time. 

We  must  continually  bear  in  mind  the  difference  between  a  local 
and  a  general  increase  in  tension.  Inasmuch  as  the  pressure  effects  of 
a  local  process  are  greater  in  its  immediate  neighborhood  than  at  a 
distance,  and  inasmuch  also  as  there  is  considerable*  pressure  dis- 
continuity between  the  three  intracranial  compartments,  owing  to 
the  fairly  rigid  partitions  formed  by  the  f alx  and  tentorium  cerebelli, 
a  local  pressure,  let  us  say  over  one  hemisphere,  may  exceed 
the  local  arterial  pressure  and  lead  to  a  local  anemia  sufficient  to 
throw  the  adjoining  parts  of  the  brain  out  of  function  without 
seriously  affecting  the  other  hemisphere  or  the  subtentorial  struc- 
tures, of  which  the  medulla  is  of  prime  importance.  On  the  other 
hand,  if  a  compression  of  like  degree  had  been  distributed  equally 
throughout  the  cranial  chamber  by  means  of  fluid  let  into  the  sub- 
dural space  under  pressure,  a  generalized  anemia  would  have  followed 
and  death  would  have  ensued  from  implication  of  the  vital  centers 
in  the  medulla.  In  a  similar  way  we  may  produce  general  com- 
pression and  elicit  the  symptoms  in  their  successive  stages  by  pres- 
sure on  the  sac  of  a  cephalo  or  meningomyelocele. 
13764— 17— .5 


66  WAE  SURGERY   OF   THE   NERVOUS  SYSTEM. 

As  the  medullary  centers  are  the  crux  of  the  situation,  it  can  be 
readily  inferred  that  an  acute  local  compression  in  the  neighborhood 
of  the  medulla  is  just  as  serious  as  a  general  compression  of  like 
degree,  whereas  over  the  hemispheres  a  much  higher  grade  of  local 
compression  is  possible  without  producing  death.  Thus  it  is  that  an 
arterial  hemorrhage  (apoplexy)  may  occur  in  one  of  the  hemispheres 
and  lead  to  an  absolute  local  anemia,  since  the  pressure  of  the  ex- 
travasation is  equal  to  arterial  pressure  without  producing  a  cor- 
responding degree  of  anemia  of  the  medulla,  otherwise  all  of  these 
cases  would  of  necessity  be  immediately  fatal. 

It  has  been  stated  that  when  subtentorial  tension — in  other  words, 
the  pressure  against  the  medulla — reaches  the  arterial  pressure,  death 
must  ensue  in  consequence  of  anemia  of  the  vital  centers.  Certain 
reservations  must  be  made  to  this  statement,  for  if  it  implies  normal 
arterial  pressure  it  is  erroneous.  For  when  the  external  pressure 
against  the  medulla  begins  to  approach  or  equal  the  arterial  tension, 
the  anemia  stimulates  the  vasomotor  center,  the  general  arterial 
pressure  is  raised,  and  the  medullary  centers  are  again  sufficiently 
well  supplied  with  oxygenated  blood.  If  the  external  pressure  is  still 
further  raised,  the  same  response  on  the  part  of  the  vasomotor  center 
again  occurs,  and  thus  in  progressive  stages  the  arterial  tension  may 
be  raised  higher  and  higher  until,  at  times,  it  may  reach  more  than 
twice  its  normal  level. 

This  progressive  rise  in  tension  of  the  circulating  arterial  blood, 
due,  as  has  been  shown,  to  constriction  of  the  splanchnic  field,  often- 
times does  not  permanently  continue  on  the  exact  level  to  which  it 
has  been  forced — namely,  slightly  above  that  of  the  intracranial  ten- 
sion. On  the  contrary,  it  often  fluctuates  above  and  below  this  level, 
with  a  definite  periodicity  (exaggerated  Traube-Hering  waves),  and 
hence  it  is  thS-t  rhythmic  respiration  of  the  Cheyne- Stokes  type  is 
produced,  for  during  the  period  of  fall  anemia  results  and  the  res- 
piration fails;  when  the  arterial  pressure  rises  again  the  medulla  is 
resupplied  with  blood  and  respiration  is  resumed.  This  reaction  may 
continue  for  hours  and  has  been  particularly  well  described  in  Eys- 
ter's  papers. 

Finally,  a  time  comes  when  the  regulatory  mechanism  is  no  longer 
efficient  and  then,  whether  from  a  further  increase  in  external  pres- 
sure or  from  fatigue  of  the  vasomotor  activity,  the  arterial  pressure 
drops  permanently  below  the  level  of  the  pressure  exerted  against 
the  medulla;  anemia  results,  the  respiratory  center  fails,  and  the 
heart  keeps  on  beating  as  an  isolated  organ,  uncontrolled  by  vagus  or 
vasomotor  activity,  until,  after  a  variable  time,  with  fall  in  pressure 
to  zero,  it  ceases  altogether  through  asphyxiation. 

This  brief  review  of  the  phenomena,  which  have  been  experimen- 
tally observed,  may  suffice  to  show,  as  Leonard  Hill  has  emphasized,' 


MENINGES,   EPENDYMA,   AND  BEAIN.  67 

that  compression  symptoms  are  not  due  to  mechanical  excitation  or 
stinictural  injury,  but,  on  the  contrary,  to  circulatory  disturbances — 
a  primary  venous  stasis,  resulting  finally  in  capillary  anemia.  It 
serves  also  to  point  out  the  differences  between  a  local  and  a  general 
increase  in  tension :  it  shows  that  anemia  of  the  medulla  plays  the 
chief  role  in  eliciting  the  so-called  major  or  bulbar  symptoms  of  com- 
pression— namely,  the  high  blood  pressure  from  stimulation  of  the 
vasomotor  center,  the  slowed  pulse  from  vagal  stimulation,  and  the 
rythmic  respiration  of  the  Chej^ne-Stokes  type  which  hinges  on  the 
fluctuation  in  level  of  the  raised  arterial  tension,  which,  for  a  short 
period,  leaves  the  respiratory  center  anemic  and  then  resupplies  it 
with  activating  blood. 

Symptoms. — We  have  seen  that  compression  of  the  brain  can  only 
take  place  at  the  expense  of  emptying  certain  of  the  blood  vessels, 
and,  furthermore,  depending  upon  the  character  of  the  process 
through  which  the  pressure  is  exerted,  that  the  interference  with  the 
circulation  may,  on  the  one  hand,  be  confined  to  a  more  or  less  re- 
stricted field  or  may,  on  the  other,  be  generalized  over  the  entire 
cerebrum. 

In  view  of  the  gradations  of  circulatory  disturbance,  as  well  as 
of  the  symptoms  they  occasion  experimentally,  Kocher,  in  his  com- 
prehensive monograph,  has  endeavored  to  subdivide  the  progressive 
phenomena  of  compression  into  four  stages;  and  for  purposes  of 
clinical  designation  it  is  convenient  to  have  such  a  classification  of 
cases  or  of  stages  of  the  individual  case. 

His  first  stage  {Co'mpensationsstadiuii%)  corresponds  with  a  mild 
grade  of  compression,  or  with  the  early  stage  of  what  may  become 
a  severe  grade,  in  which  the  pressure  exerted  against  the  brain  by 
the  foreign  substance  is  not  sufficient  to  seriously  compromise  the 
circulation.  By  the  escape  of  cerebrospinal  fluid  and  by  a  narrowing 
of  the  venous  channels  the  process  is  accommodated  with  nothing 
more  than  a  certain  degree  of  venous  congestion,  which  may  be  local. 
Symptoms  are  in  the  main  insignificant,  particularly  if  the  process 
is  remote  from  the  medulla.  There  may  be  some  headache,  possibly 
certain  focal  symptoms  referable  to  the  site  of  the  lesion,  some  mental 
dullness,  and  little  else.  There  is  but  slight  interference  with  the 
circulation  of  the  brain  as  a  whole. 

His  second  stage  {AnfangsstadiuTn  des  manifesten  Hirndruckes) 
corresponds  with  the  beginning  failure  of  circulatory  compensation. 
There  is  sufficient  venous  stasis  to  lessen  the  normal  amount  of  blood 
flowing  through  a  considerable  part  of  the  capillary  field.  Headache 
is  more  pronounced  and  there  may  be  vertigo,  restlessness,  a  dis- 
turbed sensorium  with  excitement  or  delirium,  an  unnatural  sleep, 
etc.  Other  and  objective  symptoms  become  manifest,  particularly 
shown  as  a  slight  venous  stasis  of  the  extracranial  vessels.    The  face 


^8  WAR  SURGERY  OF   THE   NERVOUS  SYSTEM. 

appears  somewhat  cyanotic,  the  venules  of  the  eyelids  are  dilated, 
and  of  greatest  import,  a  distention  and  tortuosity  of  the  veins  radi- 
ating toward  the  optic  papilla,  with  or  without  evidence  of  begin- 
ning edema  of  the  nerve  head,  may  be  found  on  an  ophthalmoscopic 
examination.  Indications  that  the  venous  congestion  is  affecting  the 
medullary  circulation  is  shown  by  a  sloAved  pulse  and  possibly  by 
a  slight  rise  in  blood  pressure. 

His  third  stage  {Hohestadium  des  manifesten  Hirndruckes)  corre- 
sponds with  the  stage  of  widespread  capillary  anemia  brought  about 
by  further  increase  of  the  tension.  Here  the  medulla  will  not  have 
escaped  even  though  the  lesion  causing  the  pressure  is  a  focal  one 
and  lies  remote  from  the  hind  brain.  The  period  of  vasomotor 
regulation  has  set  in  with  its  high  blood  pressure,  and  this,  com- 
bined with  its  vagal  quality,  gives  to  the  pulse  its  so-called  "  bound- 
ing" character.  The  rise  in  arterial  pressure  may  exhibit  fluctua- 
tions in  level,  which  can  easily  be  recorded  on  a  sphygmomanometer, 
even  when  they  are  not  appreciable  to  the  finger.  These  are  accom- 
panied by  rhythmicities  in  respiration,  which  may  acquire  the  typical 
Cheyne-Stokes  type  with  periods  of  absolute  apnea;  by  rhythmic 
alterations  also  in  the  size  of  the  pupils ;  by  a  wavering  increase  and 
lessening  of  the  depth  of  stupor,  so  that  with  the  "up  wave"  in 
pressure,  the  patient  may  moan,  become  irritable,  and  thrash  about, 
with  the  "  down  wave  "  be  deeply  comatose ;  and  by  other  signs  indic- 
ative of  the  vasomotor  rhythm.  The  pulse  is  slowed  even  to  40  or 
50  beats  per  minute.  The  choking  of  the  optic  disks  is  more  pro- 
nounced. The  reflexes  may  become  abolished.  Cyanosis  of  the  face 
is  extreme,  the  respiration  snoring,  and  the  patient  approaches  the 
brink  of  failure  of  the  regulatory  vasomotor  responses. 

In  the  fourth  or  terminal  stage  {LdhTnungsstadmm)  compensation 
on  the  part  of  the  arterial  tension  shows  signs  of  failure;  there  are 
irregular  cardiac  and  respiratory  efforts,  the  pulse  grows  rapid,  coma 
deepens,  there  is  complete  muscular  relaxation,  the  pupils  become 
widely  dilated,  and  with  the  permanent  fall  in  blood  pressure  there  is 
a  cessation  of  all  cerebral  function  with  respiratory  paralysis. 

Prognosis. — States  of  compression  not  only  vary  so  greatly  in 
degree,  but  also  may  be  due  to  such  a  variety  of  lesions  that  it  is  im- 
possible to  consider  fully  the  course  and  prognosis  of  the  condition, 
even  as  it  appears  in  any  single  malady.  The  pressure  effects  of  a 
tumor  or  of  chronic  hydrocephalus,  for.  example,  differ  materially 
from  those  of  the  acute  lesions  that  have  been  described.  Possibly 
because  they  represent  asthenic  states  they  do  not  exhibit  the  same 
pronounced  responses  on  the  part  of  the  vasomotor  center  that  char- 
acterize other  and  sthenic  conditions.  The  slow  progress  of  the  dis- 
ease may  allow  of  a  circulatory  adjustment  not  possible  in  the  more 
acute  lesions,  and  although  a  sudden  death  from  compression  some- 


MENINGES,  EPENDYMA,  AND  BRAIN.  69 

times  befalls  these  patients,  it  is  apt  to  be  due  to  paralysis  of  vital 
centers  by  invasion  or  by  a  suddenly  forming  local  edema. 

In  the  acute  cases,  those  with  hemorrhage  for  example,  the  prog- 
nosis hinges  on  the  size  of  the  compressing  mass,  the  rapidity  of  its 
formation,  the  length  of  time  which  has  elapsed,  and  the  stage  of 
compression  which  is  reached.  A  patient  in  the  third  stage,  with  high 
blood  pressure,  and  especially  when  respiratory  difficulties  with  snor- 
ing or  rhythmic  alterations  are  in  evidence,  must  be  regarded  as  in  a 
most  precarious  condition.  For,  even  though  the  pressure  may  not 
advance  and  though  the  vasomotor  mechanism  suffices  to  tide  over 
the  threatened  medullary  anemia,  there  is  always  a  chance  that  an  in- 
halation pneumonia  may  follow.  The  immediate  prognosis  for  life 
in  all  cases  which  do  not  reach  the  "  high  stage  of  manifest  com- 
pression "  is  good,  although  the  extent  of  damage  from  the  local  le- 
sion, whatever  it  may  be,  may  suffice  to  leave  incapacitating  paralyses. 
This,  however,  is  another  story,  to  be  taken  up  with  the  consideration 
of  the  various  lesions  which  produce  compression. 

Treatment. — Only  certain  general  rules  can  be  laid  down ;  the  more 
specific  ones  must  be  deferred  for  other  sections.  Needless  to  say, 
we  must  meet  with  mechanical  measures  a  condition — viz,  pressure — 
which  is  produced  by  mechanical  forces.  This  means,  on  the  one  hand, 
a  removal  of  the  source  of  pressure,  be  it  an  accessible  clot  or  abscess, 
a  tumor  or  increase  of  cerebrospinal  fluid;  on  the  other  hand,  a  re- 
lease from  the  effects  of  the  lesion  by  an  opening  in  the  skull — a  de- 
compression, in  other  words — in  case  the  lesion  is  inaccessible  or  is 
irremovable,  as  in  edema,  etc.  The  surgical  methods  of  accom- 
plishing these  results  will  be  considered  elsewhere. 

There  are  two  other  measures  seemingly  less  radical  than  a  cranial 
operation,  both  of  which  have  their  advocates,  both  of  which  possess 
elements  of  danger — lumbar  puncture,  with  the  idea  of  making  room 
by  removing  fluid,  and  venesection,  with  the  purpose  of  lowering  the 
high  blood  pressure  and  of  "  depleting  "  the  brain.  In  cases  of  com- 
pression of  high  grade  a  lumbar  puncture  may  be  promptly  fatal, 
owing  presumably  to  the  fact  that  the  intracranial  pressure  wedges 
the  medulla  and  lips  of  the  cerebellum  into  the  foramen  magnum 
when  the  support  of  the  spinal  fluid  has  been  removed.  Numerous 
sudden  fatalities  have  been  recorded  as  a  result  of  this  measure. 

Venesection,  particularly  in  cases  of  compression  from  hemorrhage, 
has  been  considered  advisable  on  the  view  that  the  high  arterial 
pressure  is  the  cause  of  the  hemorrhage  and  is  likely  to  increase  the 
bleeding,  rather  than  that  it  represents  a  conservative  process  on  the 
part  of  the  organism  to  overcome  cerebral  anemia.  Falkenheim  and 
Naunyn  recommend  that  the  blood  pressure  shoidd  be  supported  by 
every  means  in  these  cases.  Bergmann  and  Hill,  on  the  other  hand, 
are  inclined  to  the  traditional  treatment  of  lowering  it  by  blood- 


70  WAR   SUEGERY   OF    THE   NERVOUS   SYSTEM. 

letting.  It  has  been  my  experience,  both  in  the  laboratory  and  clinic, 
to  see  disastrous  results  from  venesection  with  lowering  of  blood  pres- 
sure in  cases  of  compression  in  its  third  or  highest  stage.  Only  in 
cases  which  rest  in  the  earlier  stages,  with  an  abundant  reserve  on 
the  i^art  of  the  vasomotor  center,  can  blood  be  withdrawn  with  im- 
punity, and  in  these  cases  there  is  rarely  any  symptomatic  indication 
for  bleeding. 

3.  The  psychoses  and  insanity  following  cranial  injuries.^x^berrant 
mental  processes  are  a  common  result  of  injuries  to  the  head.  We 
may  consider  (1)  their  immediate  and  (2)  their  late  manifestations. 

(1)  The  imnfnediate  clisturhances. — In  reviewing  the  symptoms  of 
concussion  and  contusion  some  of  the  acute  symptoms  have  been 
recorded.  After  the  usual  initial  period  of  unconsciousness  the 
patient  remains  stunned  or  dazed  for  a  variable  period.  He  suffers 
from  headache ;  becomes  dizzy ;  is  somewhat  nauseated  on  change  of 
position ;  is  often  in  a  dreamy  condition  of  sopor,  from  which  he  can 
be  aroused  for  a  few  moments  with  an  apparent  feeble  grasp  of  his 
situation,  but  into  which  he  soon  lapses  again.  He  may  pass  from 
this  dull,  stuporous  state  into  an  active  one,  accompanied  by  violence, 
delusions,  disorientation,  and  delirium.  This  condition  may  become 
protracted  over  a  period  of  a  few  weeks  and  represents  a  primary 
trcmmatiG  insanity.  There  is  often  fever.  Forcible  restraint  of  these 
patients  is  at  times  necessary. 

Complete  recovery  after  these  symptoms  with  a  defective  memory 
of  the  events  connected  with  them  is  not  unlikely,  even  in  the  extreme 
cases;  and  it  is  quite  probable  that  they  are  often  due  to  states  of 
acute  edema.  I  have  seen  patients  in  whom  compression  symptoms, 
even  to  the  point  of  medullary  paralysis,  were  present,  and  in  whom 
a  decompressive  operation  disclosed  an  abundance  of  sterile  fluid 
under  pressure  (acute  serous  meningitis). 

(2)  The  late  or  residual  disturhances. — These  occur  in  a  group  of 
cases  which  make  a  satisfactory  and  early  recovery  from  the  injury, 
but  show  after-effects — ^the  so-called  "  posttraumatic  neuroses." 
These  patients  complain  of  sensations  of  pain  on  pressure  or  pares- 
thesia of  one  sort  or  another,  often  referred  to  the  seat  of  the  pri- 
mary external  injury.  They  have  attacks  of  dizziness,  irritability, 
and  nervousness.  Their  traits  may  change;  formerly  good  natured, 
thej^  become  brooding,  moody,  introspective,  irascible,  and  even  vio- 
lent at  times.  They  are  forgetful,  make  stupid  blunders,  are  slow 
of  thought,  have  no  power  of  concentration,  and  hence  their  capacity 
for  continuing  their  former  occupation  is  greatly  lessened.  There  is 
often  excessive  sensitiveness  of  the  head  to  jars  or  noises,  and  a  stoop- 
ing posture  is  not  tolerated.  Natural  sleep  is  affected.  They  are 
most  intolerant  of  alcohol  or  tobacco  in  amounts  previously  taken 
without  ill  effect.     They  are  very  susceptible  to  febrile  disorders. 


MENINGES,   EPENDYMA,   AND  BRAIN.  71 

Though  no  objective  signs  accompany  these  complaints,  the}^  are  so 
uniform  from  case  to  case  that  the  symptoms  can  not  be  regarded 
as  other  than  genuine.  They  are  a  frequent  source  of  litigation. 
Epilepsy  not  uncommonly  occurs  and  attempted  suicide  is  not  un- 
usual. These  patients  often  clearly  deA^elop  a  secondary  traumatic 
insanity. 

There  seems  to  be  no  definite  relation  between  an}'  special  types 
of  lesion  and  the  particular  from  of  psychosis  which  may  follow. 
Simple  concussion  or  contusion,  Avith  or  without  definite  fracture, 
fractures  of  the  base  or  of  the  convexity,  cranial  injuries  leading  to 
loss  of  substance  or  otherwise,  gunshot  injuries,  and  other  forms  of 
lesion  may  at  times  provoke  these  symptoms  in  varying  grades.  No 
more  does  there  seem  to  be  any  definite  relation  between  the  situation 
of  the  cerebral  lesion  and  the  occurrence  of  these  symptoms,  though 
one  would  suppose  that  injuries  of  the  frontal  lobe  would  be  most 
likely  to  lead  to  them.  Doubtless  a  constitutional  peculiarity,  in- 
herited weakness,  or  alcoholism  predisposes  to  post-traumatic 
psychoses. 

No  surgeon  fails  to  see  a  number  of  these  unfortunates.  They 
appear  again  and  again  in  the  same  hospital  wards,  or  more  often 
wander  from  clinic  to  clinic  in  the  vain  hope  of  securing  some  sur- 
gical relief  for  their  miseries.  Many  of  them,  particularly  when 
cranial  defects  or  local  scars  are  present,  are  subjected  to  operation 
and  reoperation  at  various  hands.  They  are  received  with  scant  wel- 
come, and  when  weary  of  their  complaint  the  ward  discharges  them 
"  untreated,"  with  a  diagnosis  of  traumatic  neurasthenia  or  neurosis. 
Thej^  finally  wear  out  the  patience  and  sympathy  even  of  their  home 
people.  Little  wonder  that  there  is  often  an  attempt,  sometimes 
successful,  at  self-descruction. 

Treatment. — As  is  the  case  with  many  of  the  sequels  of  cranial 
injury,  the  treatment  is  largely  preventive.  We  have  seen  that, 
particularly  with  the  traumatic  cerebral  lesions  of  infancy,  an  imme- 
diate "  recovery  "  without  operative  intervention  may  take  place,  and 
yet  residual  disturbances  of  serious  import,  appreciated  only  after 
some  months,  may  remain.  The  same  is  true  of  adult  lesions.  Many 
of  them  doubtless  are  beyond  the  reach  of  our  present  methods  of 
operative  treatment,  but  as  many  more  are  within  reach.  The  let- 
well-enough-alone  policy  is  a  wise  one  to  follow  under  many  condi- 
tions, particularly  when  it  is  evident  that  recovery  from  the  imme- 
diate effects  of  an  injury  will  take  place  without  surgical  interfer- 
ence; but  when  there  is  a  likelihood  that  mental  deterioration  may 
follow  such  a  "  recovery,"  it  is  shortsighted  to  neglect  any  measures 
which  may  possibly  lessen  the  probability  of  its  occurrence. 

iPreventive  measures  are  limited  to  the  period  immediately  follow- 
ing the  injury.     Needless  to  say,  when  there  is  a  palpable  fracture  of 


72  WAR   SURGERY   OF   THE   NERVOUS   SYSTEM. 

the  convexity  it  must  receive  attention,  particularly  when  it  is  com- 
minuted and  when  the  dura  has  been  injured.  If  there  is  doubt  as 
to  the  presence  of  a  depression  it  is  better  to  explore  and  determine 
the  fact.  Subdural  clots  in  particular  must  be  carefully  removed, 
and  if  possible  a  primary  or  a  secondary  closure  of  the  dura  should 
be  made  over  a  cortical  laceration.  Unless  it  will  be  in  an  obtrusive 
situation  or  on  the  forehead,  it  is  better  to  err  on  the  side  of  leaving 
a  defect  in  the  skull  than  otherwise. 

More  important  are  the  cases  without  evident  fracture,  which  are 
usually  left  to  run  their  own  course.  This  is  particularly  true  of 
basal  fractures :  For  when  they  are  accompanied  by  subdural  hemor- 
rhages, or  when  acute  edema  is  present,  leading  to  compression  symp- 
toms, a  decompressive  operation  with  evacuation  of  fluid,  bloody  or 
otherwise,  and  the  establishment  of  a  permanent  defect  under  one  or 
both  temporal  muscles,  often  serves  not  only  to  promptly  check  the 
immediate  symptoms,  but  distinctly  lessens  the  liability  of  the  late 
"neuroses."  I  am  fully  convinced  that  properly  conducted  opera- 
tions are  thus  of  the  greatest  prophjdactic  value.  Both  BuUard  and 
Spiller,  in  their  studies  of  the  late  consequences  of  cerebral  injuries^ 
have  pointed  out  that  the  post-traumatic  neuroses — other  factors  be- 
ing equal — are  less  likely  to  follow  in  cases  which  have  been  subjected 
to  operation  than  in  those  which  have  not. 

Aside  from  operation  in  the  acute  stage,  too  great  emphasis  can  not 
be  laid  on  absolute  rest  and  enforced  quiet  for  a  long  period  after 
the  injur5^  These  patients,  like  others,  are  apt  to  be  hurried  out  of 
the  hospital;  and  an  attempt  at  too  early  a  date  to  resume  their 
former  activities  often  results  in  a  disastrous  nervous  breakdown. 

Operations  for  residual  symptoms  in  their  late  stages  are  often 
most  disappointing  in  their  results.  There  is  often  some  subjective 
improvement  after  the  removal  of  a  scar,  the  repair  of  a  defect,  tre- 
phining under  a  local  point  of  tenderness,  etc. ;  but  usually  the  same 
symptoms  or  others  reappear  and  the  patient  again  seeks  a  willing 
surgeon  until  operation  becomes  a  habit  with  him.  Though  in  iso- 
lated cases  remarkable  and  sometimes  unaccountable  cures  follow 
surgical  measures,  even  in  patients  having  pronounced  symptoms  of 
long  standing,  they  are  most  exceptional. 

4.  Cranial  defects  and  their  closure. — Are  cranial  defects  of  them- 
selves prejudicial  to  the  subsequent  welfare  of  the  brain?  This 
question  is  such  a  many-sided  one  that  a  definite  answer  for  all  cases 
can  not  possible  be  given.  There  is  a  tendency  on  the  part  of  many 
surgeons  to  regard  the  pulsating  gap  in  the  cranium  as  in  a  measure 
the  cause  of  some  of  the  distressing  post-traumatic  symptoms  which 
have  been  recorded  in  the  preceding  sections,  and  hence  to  regard  it 
as  something  to  be  solidly  closed  if  possible. 


MENINGES,   EPENDYMA,   AND  BRAIN.  73 

Arguments  may  be  advunced  for  and  against  this  view.  There  is 
no  doTibt  but  that  Ave  .see  a  great  number  ol"  patients  suffering  from 
headaches,  local  discomforts,  mental  derangement,  epileps}-.  and  the 
like,  m  whom,  from  loss  of  bone  at  the  time  of  injury  or  from  subse- 
quent operations,  there  has  resulted  a  defect  too  large  for  closure  by 
natural  processes  of  repair.  Unless  it  can  be  shoAvn  that  defects  in 
general,  including  those  not  of  traumatic  origin,  <ire  attended  with  ill 
effects,  and  further,  Avhen  they  are  of  traumatic  origin,  that  their 
closure  leads  to  an  improvement  in  existing  symptoms,  it  is  natural 
to  infer  that  the  symptoms  accompanying  a  defect  are  merely  an  ex- 
pression of  the  cerebral  lesion  which  was  coincident  with  the  cranial 
injury. 

One  or  more  defects  normally  are  present  in  a  child's  skull.  We, 
with  malice  aforethought,  purposely  make  defects  in  certain  oper- 
ations— as  upon  the  Gasserian  ganglion  or  when  bone  is  removed  for 
purposes  of  decompression.  Kocher,  indeed,  goes  so  far  as  to  believe 
that  they  exert  a  beneficial  influence  in  cases  of  traumatic  epilepsy, 
so  that  in  certain  instances  he  even  advocates  their  establishment  as  a 
therapeutic  measure.  Further,  defects  even  of  large  size  and  result- 
ing from  serious  traumatic  injuries  may  not  be  accompanied  by  any 
untoward  symptoms. 

I  am  myself  inclined  to  the  view  that  closure  of  a  defect  should 
be  limited  to  those  cases  in  which  it  is  in  an  obtrusive  situation  and 
makes  an  unsightly  deformity;  to  those  in  which  local  pain  or  ten- 
derness promises  to  be  lessened ;  or  occasionally  when  the  patient  has 
an  obsession  in  regard  to  its  presence. 

So  far  as  the  condition  may  affect,  in  one  way  or  another,  the 
progress  of  symptoms  which  result  from  the  cerebral  lesion,  there 
may  be  advantages  in  having  an  opening.  It  is  presumably  a  wound 
of  the  dura  associated  with  the  defect  which  is  of  chief  consequence, 
for  without  this  the  loss  of  bone  should  have  no  more  effect  on  the 
brain  than  has  the  fontanel  of  the  infant's  skull.  When  the  dura 
has  been  injured  as  well  as  the  brain,  an  attached  scar  will  form, 
whether  or  not  there  be  a  solid  bony  covering;  and  it  is  debatable 
whether  the  irritation  of  such  a  scar  is  less  when  there  is  a  defect 
which  allows  it  to  pulsate  with  the  brain  or  when  there  is  a  solid 
covering  to  which  it  adheres.  The  restoration  of  a  smooth  and 
unattached  dural  surface  is  of  chief  moment,  and  if  this  can  be 
accomplished  it  makes  little  difference  whether  the  bone  defect  be 
closed  or  not.  A  neurogliar  proliferation  which  may  have  its  origin 
in  a  cortical  scar  will  progress,  whether  there  is  an  intact  or  open 
cranium.  There  are  many,  however,  who  believe  that  closure  of  a 
gap  in  the  skull  resulting  from  traumatism  is  of  the  highest  im- 
portance. Stieda,  voicing  von  Bramann,  has  recently  reported  a 
series  of  48  cases  from  the  latter's  clinic  in  favor  of  this  view. 


74  WAR   SURGERY   OP   THE   NERVOUS   SYSTEM. 

Should  a  closure  of  the  defect  be  considered  advisable  there  are 
several  measures  open.  At  the  time  of  the  injury  suspicious  frag- 
ments may  be  left  in  place  {primary  implantation) ,  with  drainage  as 
a  safeguard  should  necrosis  occur;  oftentimes  even  a  large,  entirely 
dislocated  fragment  may  partially  or  totally  heal  in  place.  If,  owing 
to  laceration  of  the  scalp,  the  condition  of  the  wound  is  such  that 
replacement  seems  linwise  at  the  time,  we  may  w^ait  until  it  has 
become  covered  with  healthy  granulations,  on  which  the  preserved 
fragment,  after  sterilization,  may  be  replaced  {intermediary  implan- 
tation). Finally,  if  a  wound  Mdiich  was  compound  has  been  allowed 
to  completely  cicatrize  over  the  defect  and  it  becomes  desirable  to 
close  it,  we  may  select  one  of  two  methods.  By  the  heteroplastic 
method  a  shell  of  bone,  with  its  overlying  periosteum,  is  taken  from 
elsewhere,  as  from  the  inner  surface  of  the  tibia,  and  implanted  in 
the  reopened  wound.  It  is  no  longer  a  common  practice  to  use 
heterogeneous  materials  for  this  purpose,  as  celluloid  or  silver  plates, 
though  nature  sometimes  endures  their  insertion  with  charitable 
tolerance.  By  the  autoplastic  method  a  flap  is  made,  including  the 
scalp  and  the  underlying  periosteum,  together  with  adherent  frag- 
ments of  the  outer  table,  which  have  been  chipped  away  with  a 
chisel  or  fine  saw  (Nicoladoni)  as  the  flap  is  elevated.  This  flap  is 
then  rotated  on  its  pedicle,  so  as  to  close  in  the  freshly  denuded  bone 
defect.  The  surface  from  which  the  flap  has  been  taken  is  left  to 
heal  slowly  or  it  maj^  be  covered  at  any  time  by  a  skin  graft.  This 
is  the  so-called  autoplastic  method  of  Miiller  and  Konig — an  improve- 
ment on  a  method  of  closing  defects  introduced  in  1884  by  Durante, 
which  made  use  of  the  principle  of  autoplastic  par  glissement  intro- 
duced by  Oilier. 

THE   TECHNIC    OF   INTRACRANIAL   OPERATIONS. 

The  osteoplastic  craniotomy. — Taking  this  operation  as  typical  of 
the  more  difficult  modern  cranial  procedures,  the  general  principles 
of  technic  of  cerebral  surgery  in  general  may  be  made  to  center 
about  its  description.  Many  of  the  views  to  be  expressed  are  purely 
personal  ones  and  are  given  with  the  full  knowledge  that  the  instru- 
ments and  operative  details  found  satisfactory  to  one  individual  may 
be  entirely  unsuited  to  the  operative  requirements  of  others.  Special 
training  and  familiarity  with  a  given  set  of  instruments  engenders 
facility ;  unf amiliarity,  even  with  a  better  tool,  awkwardness.  Aware 
that  I  may  be  using  to-morrow  a  different  method  from  that  to  be 
described  and  which  Da  Costa  has  called  a  "  combined  method,"  I 
nevertheless  am  assured  that  it  is  characterized  by  safety ;  and  avoid- 
ance of  operative  accidents  in  the  approach  to  a  cerebral  lesion  is, 
after  all,  the  matter  of  chief  moment. 


MENINGES^  EPENDYMA^   AND  BRAIN.  75 

General  methods  of  preparation. — -There  is  no  ward  preparation  be- 
yond abstinence  from  food  and  insuring  what  should  under  other 
circumstances  be  a  daily  occurrence — a  normal  evacuation  of  the 
bowels.  Patients  are  too  often  weakened  and  made  uncomfortable 
by  a  purge  which  acts  the  morning  of  operation.  The  scalp,  which 
may  have  been  shampooed,  is  shaved  just  before  the  operation — a 
duty  incumbent  on  the  surgeon  in  case  of  a  nervous  patient  or  a 
child.  There  has  never  been  an  infection,  even  of  a  stitch  in  the 
scalp,  in  something  over  300  cranial  operations  in  the  writer's  series. 
(Many  operators  prefer  to  have  the  scalp  shaved  and  treated  anti- 
septically  in  the  ward  on  the  preceding  day;  some  even  advocate  a 
double  preparation.)  After  shaving  there  may  be  a  preliminary 
cleansing  of  the  scalp  with  soap  and  water  and  a  soft  brush,  after 
which  the  head  is  wrapped  in  a  wet  bichlorid  towel;  the  final  prepa- 
ration is  deferred  until  after  the  anesthetic. 

Position  on  the  table. — It  is  a  great  advantage,  though  not  a  practice 
common  to  many,  to  place  the  patient  on  the  table  in  the  position 
most  favorable  for  the  operation  before  administering  the  anesthetic. 
It  shortens  the  time  as  well  as  the  depth  of  anesthetization,  for  a 
change  of  position  from  stretcher  to  table  requires  a  degree  of  nar- 
cosis greater  than  needed  for  operative  purposes;  it  insures  a  com- 
fortable position  for  the  patient  and  thus  obviates  the  strains,  back- 
ache, and  so  forth,  which  the  handling  of  a  relaxed  body  engenders. 
It  is  particularly  important  to  observe  this  rule  in  case  the  cere- 
bellum or  occipital  lobes  are  to  be  exposed. 

Many  operators  have  a  particular  form  of  headrest  for  all  cranial 
operations,  and  Horsle3\  Frazier,  Morestin,  and  others  have  described 
table  extensions  for  this  purpose.  For  the  usual  operations  on  the 
vault,  however,  I  find  that  small,  flat,  solid  pillows  or  sandbags  are 
all  that  are  necessar}^  to  turn  and  hold  the  head  in  the  desired  posi- 
tion ;  on  the  other  hand,  I  find  a  head  extension  necessary  for  cerebel- 
lar work,  chiefly  to  insure  free  respiration.  Thus  do  surgeons'  views 
differ.  Whatever  form  of  table  be  used,  however,  it  is  desirable  to 
have  the  head  end  capable  of  being  raised  or  lowered  at  will. 

The  anesthetic. — Regardless  of  the  drug  to  be  used,  it  is  essential 
that  it  be  administered  by  an  expert,  preferably  by  one  who  makes 
this  his  specialty.  Many  of  the  conditions  for  which  these  operations 
are  done  are  associated  with  cardiovascular  and  respiratory  disturb- 
ances of  cerebral  origin,  and  the  greatest  care  must  be  exercised  lest 
a  further  burden  be  imposed  by  the  anesthetic. 

In  all  serious  or  questionable  cases  the  patient's  pulse  and  blood 
pressure,  first  recorded  in  the  ward,  should  be  followed  throughout 
the  entire  procedure  by  a  hlood-pressure  apparatus  and  the  observa- 
tions recorded  on  a  plotted  chart.  Only  in  this  way  can  we  gain 
any  idea  of  physiological  disturbances — whether  given  manipula- 


76  WAR   SURGERY   OF   THE    NERVOUS  SYSTEM. 

tions  are  leading  to  shock,  whether  there  is  a  fall  of  blood  pressure 
from  loss  of  blood,  whether  the  slowed  pulse  is  due  to  compression, 
and  so  on.  A  further  necessity  is  an  artificial  respiration  ap'paratus^ 
to  be  immediately  put  into  use  in  case  there  is  failure  of  an  already 
burdened  respiratory  center,  either  from  the  anesthetic,  from  loss  of 
blood,  or  from  additional  compression  due  to  cerebral  manipulations. 

Sir  Victor  Horsely,  as  is  well  known,  is  a  strong  advocate  of  chloro- 
form combined  with  a  preliminary  hypodermic  of  morphin.  Only  a 
small  amount  of  the  drug  is  required,  except  during  the  early  and 
closing  periods  of  the  anesthetization,  and  there  is  less  likelihood  of 
subsequent  vomiting  than  when  ether  is  used.  It  is  taken  smoothly, 
without  cyanosis,  and,  furthermore,  tends  to  lower  the  blood  pres- 
sure ;  hence  there  is  said  to  be  less  bleeding  during  the  operation.  In 
this  country,  where  chloroform  is  doubtless  administered  less  well 
than  ether,  the  latter  is  the  anesthetic  of  choice  at  most  hands,  the 
primary  stage  often  being  induced  with  ethyl  chlorid.  I  believe,  with 
Kocher,  that  there  is  an  element  of  risk  in  the  lowering  of  blood 
pressure  by  chloroform ;  and  it  is  perhaps  debatable  whether  this  is 
not  a  more  certain  danger  than  the  more  active  bleeding  said  to  occur 
under  ether;  a  drug  which  tends  to  hold  the  blood  pressure  high. 
Having  had  a  fatality  from  chloroform,  I  use  it  far  less  frequently 
in  cranial  operations  than  formerly,  restricting  its  use  largely  to 
children. 

The  question  of  the  anesthetic  in  a  two-stage  operation  is  an  espe- 
cially serious  one.  Chloroform  here  would  perhaps  be  less  dangerous 
than  a  repeated  etherization.  Local  anesthesia  may  at  times  be  em- 
ployed, though  infiltration  of  the  scalp  is  difficult.  I  have  learned 
that  no  anesthetic  whatsoever  need  be  required  for  a  second-stage 
operation  limited  to  manipulations  of  dura  and  brain  after  re-reflect- 
ing the  original  bone  flap. 

Preparation  of  the  operative  field. — With  the  patient  anesthetized  and 
in  proper  position  on  the  table,  the  final  cleansing  is  done;  for  this 
alcohol  and  1 :  1000  bichlorid  solution  suffice. 

It  is  my  practice  at  this  stage,  before  the  landmarks  are  obscured 
by  the  covering  of  operative  sheets  and  towels,  to  outline  the  pro- 
posed flap  on  the  scalp  with  a  superficial  cut  of  the  scalpel.  Those 
who  have  by  long  practice  familiarized  themselves  with  craniocere- 
bral topography  can  mark  out  the  main  fissures  on  the  scalp  with 
no  greater  margin  of  error  than  when  measurements  are  employed. 
Furthermore,  as  a  large  opening  is  to  be  made,  the  accurate  determi- 
nation on  the  scalp  of  the  point  overlying  a  given  center  is  to-day 
less  essential  than  formerly,  when  an  attempt  was  made  to  approach 
it  directly  through  a  small  trephine  opening.  Those  who  are  less 
familiar  with  the  topography  of  the  brain  will  need  to  mark  out 
these  fissures  by  the  aid  of  some  one  of  the  craniometers  or  rules 


MENINGES^  EPENDYMA^  AND  BEAIN.  77 

of  measursement  Avhich  have  been  described.  As  this  is  somewhat 
time  consuming,  many  prefer  with  an  indelible  pencil  to  delineate 
these  landmarks  on  the  shaved  scalp  the  day  before. 

With  the  proposed  flap  thus  outlined  and  the  head  raised  by  a 
hand  under  the  back  of  the  neck,  a  broad  square  of  wet  bichlorid 
gauze  is  throTen  over  the  entire  head  and  over  this  is  placed  a  tourni- 
quet. 

For  the  control  of  hemorrhage  from,  the  scalp  numerous  forms  of 
tourniquet  have  been  advocated.  Many  use  a  simple  rubber  tube  or 
Esmarch  bandage,  both  of  which  are  diificult  to  apply  and  to  fasten 
Mnthout  slips  in  the  aseptic  technic ;  Crile  uses  a  rubber  dam  over  the 
entire  scalp,  which  is  thus  rendered  bloodless;  I  formerly  used  a 
pneumatic  tourniquet,  but  have  finally  come  to  a  form  of  rubber 
ring,  which  is  snapped  over  the  head  from  glabella  to  suboccipital 
region  and  which  has  a  median  tape  to  prevent  its  slipping  over 
the  eyes.  This  ring,  with  its  tape  of  proper  length,  should  have 
been  measured  before  the  operation,  and,  having  been  boiled,  it 
is  applied  by  the  operator  and  an  assistant.  Usually  all  bleeding 
from  the  scalp  is  controlled  by  the  tourniquet,  though  in  certain 
cases  of  tumor  with  marked  intracranial  stasis  some  of  the  veins 
on  the  concave  side  of  the  incision,  receiving  blood  from  the  skull, 
may  have  to  be  clamped.  Special  forceps  have  been  designed  for 
this  purpose  by  Nicholson,  Howzel,  and  Chipault.  Other  methods 
of  controlling  the  vessels  of  the  scalp  have  been  advocated;  as  (1) 
preliminary  ligation  or  temporary  closure  (Crile)  of  the  carotid; 
(2)  the  blocking  by  three  mass  ligatures  of  tissue,  including  tem- 
poral, occipital,  and  supra-orbital  arteries;  and  (3)  the  enclosure 
of  the  proposed  incision  by  a  running  suture  passed  through  the 
scalp  on  each  side  of  it  with  the  purpose  of  leaving  an  anemic  band 
of  tissue  (Heidenhain). 

With  a  proper  arrangement  of  towels  and,  finally,  a  large  opera- 
tive sheet  which  covers  the  etherizer  like  a  tent,  the  field  is  prepared 
leaving  exposed  little  more  than  the  area  encompassed  by  the  pre- 
liminary incision. 

The  osteoplastic  flap. — In  the  line  previously  scratched  on  the  scalp 
the  incision  is  made  through  gauze  and  soft  parts  down  to  the  skull, 
and  when  the  bone  is  exposed  it  can  be  opened  in  a  number  of  dif- 
ferent ways.  It  may  be  recalled  that  in  the  original  operation  as  de- 
scribed by  Wagner  (1889)  the  flap  was  outlined  with  mallet  and 
chisel,  and  Chipault,  Keen,  and  many  others  followed  his  lead.  Keen 
long  employed  a  particular  form  of  angular  gouge,  with  which  the 
incision  was  quickly  and  skillfully  made  through  the  greater  thick- 
ness of  the  skull,  the  flap  being  finally  loosened  by  a  fcAv  blows, 
which  served  to  break  such  portions  of  the  inner  table  as  had  escaped 


78  WAE  SUEGEEY   OF   THE    NERVOUS  SYSTEM. 

division.  Kiister  has  recently  advocated  a  chisel  of  different  form 
for  the  same  purpose. 

Most  operators  object  to  these  methods  on  the  score  of  possible 
concussion  even  from  the  glancing  blows  which  are  given.  Toisori 
(1891)  suggested  the  division  of  the  bone  with  a  chain  saw  passed 
between  primary  trephine  openings,  with  cutting  of  the  bone  from 
within  outward.  This  remains  a  first  principle.  Obalinski  (1897) 
recommended  for  this  purpose  the  flexible  wire  saw  (introduced  by 
Gigli,  in  1897,  for  obstetrical  purposes).  A  linear  cut  of  2  or  3  mm. 
width  through  the  full  thickness  of  the  bone  may  be  made  with  biting 
forceps  of  Montenovesi  or  Doyen  pattern,  or  with  the  cutting  hooks 
introduced  by  Dahlgren  and  De  Vilbiss.  These  instruments  progress 
slowly,  but  they  are  almost  certain  not  to  injure  the  dura  and  have 
the  advantage  of  biting  outward,  so  that  there  is  little,  if  any,  jar 
to  the  brain.  Flexible  wire  saws  may  be  used,  that  perfected  by 
Gigli  being  the  best.  As  it  cuts  from  within  outward  and  when 
taut  straightens  on  the  arc  of  the  cranial  circle,  the  saw  must  be 
guarded-  in  order  to  protect  the  dura  from  injury.  Similarly,  the 
bone  may  be  cut  between  the  primary  openings  b}^  sawing  with  a 
straight  handsaw  from  without  inw^ard  and  Doyen  has  devised  a 
special  saw  with  a  guard  for  this  purpose.  It  is  a  dangerous  tool  in 
inexperienced  hands. 

There  are,  further,  certain  craniotomes  which  cut  in  a  circular 
fashion  by  swinging  the  blade  about  a  fixed  point  and  whicn  may  be 
used  to  incise  scalp  as  well  as  bone.  The  Stellwagen  instrument 
{Annals  of  Surgery^  1902)  has  been  highly  praised  by  Philadelphia 
surgeons.  A  French  instrument  of  similar  type  was  described  by 
Codivilla  in  1900  {Revue  de  chirurgie).  Though  no  preliminary 
trephine  opening  is  needed,  these  methods  possess  the  disadvantage 
of  cutting  from  without  inward,  and  as  there  is  no  guard,  the  dura 
is  likely  to  be  injured  by  these  craniotomes  a  mouvement  circulaire, 
unless  the  membrane  is  approached  with  the  greatest  caution. 

The  electromotor  has  been  employed  to  furnish  the  driving  power 
for  a  number  of  instruments  which  possess  a  circular  or  spherical 
form  and  so  can  revolve,  such  as  burrs,  trephines,'  and  circular  saws 
(of  which  there  are  a  number  of  patterns,  Van  Arsdale's,  Powell's, 
Marsland's,  and  Doyen's).  It  has  led,  furthermore,  to  the  invention 
of  a  revolving  tool  or  fraise  with  spiral  cutting  edges,  which  is  used 
by  some  operators.  Cryer,  in  1897,  Sucleck,  in  1900,  and  Sykes  have 
all  described  similar  instruments  of  this  type,  and  though  useful 
for  certain  purposes  they  posses  the  disadvantage  for  osteoplastic 
work  of  cutting  such  a  wide  slot  that  the  replaced  flap  subsequently 
rests  on  the  dura  instead  of  on  the  bone  edges.  In  the  Doyen  type  of 
motor  there  is  a  long  flexible  arm  between  the  motor  and  the  revolv- 
ing tool,  which  is  thus  driven  from  a  distance,  as  in  the  usual  form  of 


MENINGES,   EPENDYMA,  AND  BRAIN,  79 

dental  engine.  Borchardt  (1906)  has  made  some  modifications  of  the 
apparatus,  and  Bercnt  (1904)  and  Hartley  (1907)  have  made  the 
further  great  improvement  of  having  the  cutting  tool  directly  con- 
nected with  the  motor,  which,  weighing  only  8  or  9  pounds  and 
being  capable  of  sterilization,  is  itself  held  in  the  operator's  hands. 
Hartley  has  devised  also  new  forms  of  perforators  with  serrated 
edges. 

Surigeons  who  use  electromotive  force  for  osteoplastic  operations 
are  able  to  work  very  rapidly,  and  if  this  does  not  mean  added  risk 
of  accident  it  is  desirable.  However,  having  witnessed,  twice  from  a 
Doyen  circular  saw,  and  once  from  a  Cryer  drill,  what  I  regard 
as  a  most  serious  accident — namely,  the  division  of  bone  and  dura 
at  the  same  time,  owing  to  the  fact  that  the  guide  of  the  speeding 
instrument  worked  its  way  through  the  adherent  membrane  instead 
of  separating  it  from  the  skull — I  have  clung  to  the  somewhat  slower, 
but  certainly  less  dangerous  operation  by  hand-driven  instruments. 

The  methods  of  procedure  which  suit  my  own  personal  needs  may 
be  described. 

The  osteoplastic  procedure. — This  combines  the  following  principles : 
Of  division  l)etween  primary  openings  (Toison)  ;  of  incision  by  an 
advancing  instrument  from  a  single  opening;  of  making  all  cuts  from 
within  outmard;  of  leaving  a  heveled,  flap. 

A  primary  opening  through  the  thickest  part  of  the  exposed  cra- 
nium, usually  near  the  parietal  eminence,  is  made  with  a  hand  tre- 
phine, which  should  be  of  generous  size,  with  a  crown  of  fully  2|  cm. 
I  prefer  a  trephine  of  the  Gait  conical  pattern  with  a  beveled  edge; 
it  is  the  safest  instrument  and  obviates  the  necessity  of  an  extractor 
{tire-fond.)  for  the  button,  since,  owing  to  the  width  of  the  super- 
ficial cut,  it  can  easily  be  tilted  out.  In  France  the  old  form  of  cylin- 
drical trepan  is  still  in  general  use.  Bleeding  from  diploetic  vessels 
in  certain  cases  of  tumor  may  be  severe.  A  fatal  case,  indeed,  of  this 
sort  has  been  reported  by  Eansohoff.  It  may  be  controlled  by  the 
proper  use  of  Horsley's  wax,  with  which  the  beveled  teeth  of  the  tre- 
phine may  be  filled.  One  or  more  secondary  openings  (one  is  usually 
sufficient)  at  the  upper  edge  of  the  incision  are  made  with  a  Doyen 
burr.  With  a  long-handled  blunt  dissector  or  dural  separator  intro- 
duced through  the  large  trephine  opening  the  dura  is  separated  from 
the  bone  between  these  openings.  On  withdrawing  the  dissector  the 
intradural  pressure  suffices  to  press  dura  against  bone  again  and  thus 
to  stop  the  bleeding.  From  the  two  trephine  openings  the  lateral 
edges  of  the  flap  are  then  cut  downward  toward  the  base,  in  line  with 
the  skin  incision.  The  first  |  inch  of  these  lateral  cuts  is  made  with 
Montenovesi  forceps  with  a  3  mm.  incision,  followed  by  the  Dahl- 
gren  forceps,  as  the  thinner  bone  near  the  temporal  region  is  ap- 
proached.    A  Gigli  wire  saw  is  then  passed  on  a  guide  (of  which 


80  WAR  SURGERY   OF   THE   NERVOUS  SYSTEM. 

there  are  numerous  forms)  between  the  two  primary  openings,  and 
the  mesial  edge  of  the  flap  is  cut  on  a  broad  bevel.  (This  is  an  im- 
portant detail,  for  it  enables  the  subsequent  solid  replacement  of  the 
flap  without  danger  of  its  being  driven  inward  by  a  snug  pressure 
bandage. ) 

The  flap  is  then  forced  back  by  the  insertion  of  blunt  instruments 
around  the  edges  and  is  broken  across  at  its  base.  As  Hartley  has 
emphasized,  all  flaps  made  on  the  cranial  vault  should  radiate  toward 
the  temporal  bone  as  a  base,  since  this  is  the  thinnest  part  of  the  cal- 
varium  and  most  easily  broken.  Provided  the  flap  includes  the  region 
of  the  pterion,  the  meningeal  artery  may  be  torn,  OAving  to  its  having 
channeled  the  broken  bone.  The  vessel  should  be  ligated  at  its  lowest 
point  of  exposure  by  making  at  a  distance  a  small  opening  in  the 
dura,  through  which  a  grooved  dissector  is  inserted  and  on  which 
the  curved  needle  should  be  passed  to  avoid  the  chance  injury  of  some 
cortical  vessel.  Bleeding  from  the  expansions  of  the  lateral  sinus,  in 
case  they  have  been  exposed  by  a  high  flap,  is  best  controlled  by  the 
pressure  of  sterile  absorbent  cotton,  pledgets  of  which  I  find  to  be 
as  valuable  as  a  hemostatic  agent  for  the  intracranial  part  of  the 
work  as  is  wax  for  the  bone  itself.  Horsley  uses  hot  saline  or  weak 
bichlorid  irrigations. 

The  intracranial  procedures. — At  this  stage,  if  there  has  been  a  fall 
of  blood  pressure  from  loss  of  blood,  the  further  progress  of  the 
operation,  especially  in  tumor  cases,  may  well  be  postponed  for  a 
second  session.  The  question  of  a  two-stage  operation  and  the  pos- 
sibility of  a  second  stage  without  anesthesia  has  been  considered 
under  the  treatment  of  tumors.  If  there  is  no  contraindication  on 
this  score,  the  dura  is  opened  in  a  line  concentric  with  the  bone  inci- 
sion, leaving  plenty  of  margin  for  subsequent  suture.  The  mem- 
brane should  be  incised  on  a  grooved  director,  especially  if  there  is 
increased  tension,  lest  the  pia-arachnoid  be  injured.  The  incision 
should  not  be  made  too  near  the  median  line,  lest  the  edges  of  the 
parasinoidal  expansions,  or  the  veins  entering  them,  be  wounded. 
If  the  mesial  edge  of  the  hemisphere  is  to  be  exposed,  it  is  well  to 
open  the  dura  in  this  direction  by  a  separate  radial  cut,  and  if  neces- 
sary to  rongeur  away  some  of  the  bone  toward  the  median  line.  This 
is  preferable  to  an  attempt  at  exposure  of  the  mesial  edge  (foot  area) , 
through  the  primary  osteoplastic  flap — a  procedure  necessarily  at- 
tended with  a  great  loss  of  blood. 

If  the  expected  lesion  is  not  disclosed  and  if  the  topography  is  not 
perfectly  clear,  the  fissura  centralis  may  have  to  be  determined  by 
faradization  of  the  cortex.  A  long  glass  unipolar  electrode  carrying 
a  fine  platinum  wire  core,  coiled  into  a  spiral  at  the  end  according 
TO  Sherrington's  plan,  in  order  to  obviate  puncturing  the  pia-arach- 
noid, is  used  for  stimulation.    The  other  pole  is  attached  to  an  ex- 


MENINGES,   EPENDYMA,   AND  BRAIN.  81 

tremity,  preferably  on  the  homolateral  side.  The  current  should  be 
just  strong  enough  to  contract  exposed  muscle — some  of  the  temporal 
fibers  are  usually  available  for  this  test.  If  there  is  an  abundance 
of  cerebrospinal  fluid  in  the  arachnoid  spaces,  it  must  be  evacuated 
by  pricking  the  membrane  as  it  bridges  the  sulci;  and,  further,  the 
patient  must  not  be  too  deeply  under  the  anesthetic.  No  motor  cor- 
tex, unless  there  is  complete  degeneration  of  the  pyramidal  tract,  fails 
to  give  responses  if  these  precautions  are  observed. 

If  an  incision  of  the  cortex  is  necessary,  whether  for  exploration, 
for  extirpation  of  an  area  in  focal  epilepsy,  or  for  the  removal  of 
brain  tumors,  the  cortical  vessels  to  be  diA'ided  must  first  be  ligated 
on  each  side  of  the  proposed  incision,  which  should,  if  possible,  be 
confined  to  the  exposed  surface  of  a  convolution  and  should  not  cross 
a  sulcus.  The  finest  strands  of  split  silk,  preferably  black,  should 
be  used  for  these  ligatures,  and  they  should  be  passed  around  the 
vessels  with  delicate  curved  French  needles,  which  are  introduced 
and  emerge  in  nonvascular  areas.  With  these  precautions  the  sub- 
cortical  manipulations  can  usually  be  conducted  with  but  little  loss 
cf  blood,  even  in  most  cases  of  tumor  extirpation.  Tumors  which 
have  approached  and  involved  the  cortex  must  be  surrounded  by  a 
similarly  placed  double  row  of  ligatures,  between  which  the  incision 
is  made.  Subsequent  dissections  are  made  with  blunt  instruments, 
and  momentary  pressure  of  cotton  pledgets  w^ill  usually  check  the 
oozing. 

A  brain  which  tends  to  protrude  may  sometimes  be  dropped  back 
by  elevation  of  the  head  and  trunk  or  by  evacuating  cerebrospinal 
fluid.  This  can  at  times  be  accomplished  by  opening  the  arach- 
noid spaces  and  by  milking  out  the  fluid;  at  other  times  a  lumbar 
puncture  may  be  necessary,  and  the  removal  of  fluid  in  this  way 
during  the  course  of  an  operation  is  of  great  help  under  many  cir- 
cumstances, and  is  free  from  the  danger  which  attends  a  similar 
proceeding  when  the  skull  is  closed. 

Closure. — Unless  an  irremovable  growth  indicates  the  necessity  of 
permanent  decompression,  an  accurate  approximation  of  the  dura 
in  its  two  layers  is  desirable;  this  should  be  painstakingly  done,  to 
prevent  the  formation  of  adhesions  of  their  re- formation  if  they  have 
been  found  and  divided,  and  have  been  productive  of  symptoms,  as 
in  epilepsy.  If  there  is  a  large  cortical  defect,  as  after  the  removal 
of  a  growth,  or  if  the  brain  has  receded  from  its  normal  level,  the 
space  may  well  be  filled  with  warm  salt  solution  before  closing  the 
dura.  The  bone  flap  is  solidly  replaced  and  the  scalp  is  in  turn  ac- 
curately approximated  in  a  broad  surface.  It  is  well  to  draw  to- 
gether the  galea  aponeurotica  by  a  few  buried  sutures  before  closing 
the  outer  layer.    For  the  latter,  many  use  a  continuous  suture,  which 

13764—17 6 


82  WAR  SURGERY   OF   THE   NERVOUS  SYSTEM. 

has  the  advantage  of  speed.  Inasmuch  as  the  closure  in  many  cases 
is  completed  before  the  tourniquet  is  removed,  I  feel  the  need  of  a 
more  accurate  and  solid  approximation.  This  is  done  by  rapidly 
placing  about  the  incision  a  series  of  straight,  round-pointed  cambric 
needles,  which  serve  to  keep  the  edges  everted  as  each  suture  is  tied, 
and  thus  to  assure  a  ridge  of  tissue  with  a  flat  approximation  which 
prevents  subsequent  bleeding  from  the  vessels  of  the  scalp. 

Drainage  is  occasionally  advisable — perhaps  in  20  per  cent  of  the 
cases — but  it  should  be  avoided  if  possible.  It  is  necessitated  by  con- 
stant oozing  from  the  exposed  parasinoidal  sinuses,  for  othewise  an 
extradural  clot  may  form.  Marion  drains  directly  through  the  center 
of  the  flap,  in  which  a  new  opening  has  been  drilled.  I  prefer  to 
take  advantage  of  the  trephine  openings  already  made  at  the  upper 
angles  of  the  flap.  The  drains,  of  cigarette  form,  covered  with  pro- 
tective gauze  so  that  they  may  be  easily  withdrawn,  are  led  out,  not 
through  the  original  incision,  but  through  puncture  wounds  made 
through  the  scalp  2  cm.  to  the  outer  side;  this  insures  an  oblique 
passage  which  can  be  occluded  by  pressure  in  case  there  should  be  a 
tendency  for  cerebrospinal  fluid  to  escape  after  the  drains  have  been 
withdrawn.  Kocher  has  devised  small  silver  tubes  for  drainage  in 
similar  fashion,  and  they  serve  the  purpose  admirably. 

The  wound  is  partly  dressed  and  pressure  is  applied  before  the 
tourniquet  is  removed;  then  an  abundant  dressing  with  an  outer 
starched  bandage  is  emplo3^ed.  The  ears  should  be  carefully  pro- 
tected with  cotton  to  prevent  discomfort  from  pressure. 

The  first  dressing  is  made  in  48  hours,  when  the  drains,  if  used, 
and  all  the  sutures  are  removed. 

Special  operations. — Although  these  osteoplastic  resections  typify  the 
methods  of  approaching  the  brain  in  a  large  percentage  of  our 
cases,  they  are  not  particularly  applicable  to  operations  elsewhere 
than  upon  the  vault,  nor  are  they  necessary  in  cases  in  which  from 
the  first  it  is  evident  that  bone  must  be  permanently^  removed  for 
decompressive  purposes.  Certain  principles  relating  to  these  special 
operations  may  deserve  mention. 

Suboccipital  operations. — For  the  exposure  of  subtentorial  lesions 
(such  as  tumors  of  the  cerebellum  or  of  the  lateral  recess,  a  basilar 
meningitis  to  be  drained,  the  freeing  of  adhesions  about  the  fourth 
ventricle  resultant  to  an  old  inflammation,  etc.)  the  principles  of 
tourniquet  and  bone  flap  are  not  applicable.  In  this  situation,  just 
as  under  the  temporal  muscle,  owing  to  the  possibility  of  subsequent 
firm  closure  under  muscle,  there  is  less  reason  for  preservation  of 
bone.  Though  many  surgeons  place  the  patient  on  the  side  for  these 
operations,  I  much  prefer  a  symmetrical,  face-down  position,  par- 
ticularly as  a  bilateral  exposure  is  usually  called  for.  This  position 
interferes  greatly  with  respiration  unless  the  shoulders  are  held  away 


MENINGES,  EPENDYMA,  AND  BRAIN.  83 

from  the  table  so  as  to  allow  of  free  thoracic  movements,  and  conse- 
quently, for  these  cases  I  have  devised  a  table  extension  with  shoulder 
supports  and  a  separate  crutch  with  a  horseshoe-shaped  top  in  which 
the  forehead  and  cheek  bones  comfortably  rest.  The  anesthetic  is 
sprayed  against  a  mask  attached  under  the  "  horseshoe." 

It  has  been  mentioned  in  the  section  on  tumors  that  a  bilateral 
exposure  of  both  cerebellar  lobes  is  desirable  to  allow  of  dislocation 
outward  of  the  normal  lobe  during  the  manipulations  of  the  other. 
Hence  I  prefer  a  symmetrical  form  of  approach,  and  find  that  a 
median  incision,  which  divides  the  soft  parts  down  not  only  to  occi- 
put, but  to  the  spinous  processes  of  the  upper  cervical  vertebrae,  in 
addition  to  the  usual  curvilinear  cut  over  the  occipital  ridge  ("  cross- 
bow "incision,  gives  additional  room,  owing  to  the  lateral  reflection 
of  the  flaps.  A  fringe  of  muscle  and  aponeurosis  together  with  galea 
is  carefully  preserved  at  the  upper  edge  for  subsequent  union  by 
suture  with  the  reflected  muscle  flaps.  The  bone  is  bared  and,  after 
making  bilateral  primary  openings,  is  rongeured  away — upward,  so 
as  to  expose  the  lateral  sinus  on  each  side;  across  the  median  line, 
leaving  intact  the  bone  over  the  torcular ;  and  then  downward,  so  as 
to  include  the  posterior  half  of  the  foramen  magnum.  The  dura  is 
then  widely  opened  and  the  midoccipital  sinus,  if  present,  is  ligated. 

This  opening,  through  the  possibility  of  cerebellar  dislocation, 
gives  a  wide  area  of  exposure,  either  of  the  fourth  ventricle  or  of  the 
structures  in  the  cerebellopontine  angle ;  and  it  is  desirable,  not  only 
for  exploration,  but  for  decompression  of  incurable  tumors  in  this 
situation,  that  it  be  bilateral.  There  are  certain  points  in  the  bone 
where  hemorrhage  may  be  met  with  in  these  operations,  and  especial 
care  must  be  taken  at  the  torcular  and  at  the  approach  to  the  mastoid 
processes.  Intracranially  a  large  vein  often  bridges  across  the  sub- 
dural space  at  the  side  of  the  cerebellum,  injury  to  which  should 
be  avoided  if  possible. 

Temporal  operations. — Operations  either  for  decompression  purposes, 
or  in  exploration  for  hemorrhage,  tumor,  or  abcess  in  the  temporal 
lobe,  or  for  lesions  in  the  middle  cranial  fossa,  are  convenientlv  car- 
ried out  by  simple  splitting  of  the  temporal  muscle  without  division 
of  the  fibers.  Here  again,  as  in  the  occipital  operation,  there  is  no 
reason  for  the  preservation  of  the  bone,  as  there  remains  a  secure 
muscular  protection,  which  prevents  too  great  bulging  in  case  of  in- 
creased tension,  or  an  obtrusive  and  deforming  depression  in  its  ab- 
sence. The  incision  through  the  scalp  may  be  made  parallel  to  the 
muscle  fibers  or  as  a  curved  incision  across  them.  In  removing  the 
bone,  flat-bladed  rongeur  forceps  are  necessary,  as  the  muscle  can 
not  be  lifted  far  away  from  the  skull,  and  care  must  be  taken  not  to 
injure  the  meningeal  in  case  it  lies  in  a  canal  at  the  lower  angle  of 


84  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

the  parietal  bone.  A  large  defect  giving  free  exposure  of  the  tem- 
poral lobe  may  be  made  in  this  way. 

Should  it  be  necessary  to  bring  into  view  the  base  of  the  skull,  as 
in  operations  upon  the  Gasserian  ganglion  or  for  tumors  in  its  neigh- 
borhood, it  is  better  to  divide  the  muscle  fibers  without  attempting 
a  splitting-  operation. 

These  basilar  operations  through  the  temporal  region  may  be  car- 
ried so  far  inward  as  to  expose  the  hypophysis.  A  view  at  this 
depth,  however,  requires  such  a  degree  of  elevation  of  the  brain  that 
it  is  necessary  to  have  a  large  cranial  opening  in  order  to  allow  of 
dislocation  outward,  which  obviates,  in  a  measure,  the  danger  of  com- 
pression effects.  As  conducted  by  Horsley  in  his  remarkable  series 
of  cases,  this  is  an  intradural  operation  conducted,  after  making  a 
widfe  opening  in  the  skull,  directly  under  the  temporal  lobe:  after 
its  exposure  the  new  growth  situated  in  the  sella  turcica  is  removed 
Avith  the  proper  form  of  curet. 

Frontal  oferations  may  be  required  for  the  exposure  of  lesions  of 
the  orbital  or  mesial  surfaces  of  the  frontal  lobe  or  anterior  end  of 
the  corpus  callosum.  An  approach  to  the  pituitary  fossa  has  also 
been  attempted  by  Krause  directly  under  the  frontal  lobes  after  turn- 
ing doAvn  a  large  frontal  bone  flap.  Similar  methods  have  been  sug- 
gested by  Kiliani  (1904)  and  by  Buret  (1905),  while  Hartley  (1907) 
advocates  a  bilateral  flap  with  a  pedicle  in  each  temporal  fossa. 
Here,  too,  a  great  deal  of  room  for  dislocation  is  necessary,  and  it 
would  seem  that  the  chance  of  frontal-lobe  injury,  far  more  serious 
than  an  equal  degree  of  bruising  of  the  temporal  lobe,  would  make 
Horsley's  route  preferable. 

These,  like  many  other  of  the  more  serious  and  dangerous  of  the 
modern  intracranial  operations,  should,  for  the  time  being  and  until 
their  veriest  detail  is  established  on  an  unquestioned  basis,  rest  in 
the  hands  alojie  of  those  specially  trained  in  the  conduct  of  cerebral 
operations.  The  advance  of  neurological  surgery  is  greatly  impeded 
by  the  prevailing  impression  in  regard  to  its  dangers  and  general 
futility — an  impression  due  in  large  measure  to  the  unsuccessful  at- 
tempts of  the  untrained  and  inexpert. 


Part  3 

THE   VESTIBULAR  APPARATUS   IN   RELATION   TO   THE 
DIAGNOSIS  OF  INTRACRANIAL  LESIONS. 

(From   Equilibrium  ami  Vertigo.     By  Isaac  H.   Jones,   M.   D.     Published  by 
J.  B.  Lippincott  Company.) 

THE  EAR  AND  THE  NEUIIOLOGIST. 

The  intimate  relation  of  the  ear  to  the  central  nervous  system 
makes  this  study  of  Neuro-otology  of  especial  interest  to  the  neurol- 
ogist. The  value  of  an  eye  examination  in  neurologic  cases  is  now 
universally  recognized.  The  study  of  the  eye  grounds,  the  field  of 
vision,  pupillary  reaction  to  light  and  accommodation  and  the  degree 
of  function  of  the  eye  muscles,  furnishes  valuable  information  to  the 
neurologist.  Based  on  the  opinion  of  the  neurologists  and  ophthal- 
mologists most  acquainted  with  these  ear  tests,  it  would  seem  safe  to 
assert  that  of  the  two  methods  of  approach,  very  much  more  definite 
information  can,  as  a  rule,  be  had  from  the  examination  of  the  ves- 
tibular apparatus  than  from  an  eye  examination.  The  value  of  ear 
examinations  in  neurologic  cases  is  recognized  in  Vienna  to  the  ex- 
tent that  no  examination  of  a  neurologic  case  is  considered  complete 
without  a  report  from  the  otologist  as  to  the  condition  of  the  ves- 
tibular apparatus. 

The  neurologist  is  not  only  concerned  with  the  problems  of  equi- 
libration which  have  already  been  presented,  but,  in  addition,  he  has, 
in  these  ear  examinations,  a  very  definite  help  in  many  perplexing- 
diagnoses.  The  ear  tests  are  of  particular  value  in  making  a  differ- 
ential diagnosis  between  labyrinth  and  intracranial  lesions  and  in 
furnishing  additional  data  in  intracranial  loc*ilization. 

It  is  Avell  known  that  nystagmus  and  vertigo,  with  loss  of  equili- 
bration, associated  perhaps  with  nausea  and  vomiting,  may  be  pro- 
duced either  by  a  disturbance  of  the  internal  ear  or  by  an  intracranial 
lesion.  In  many  instances  the  symptoms  of  internal  ear  disturbance 
and  of  a  cerebellar  lesion  are  identical.  It  not  rarely  happens  that  a 
careful  neurologic  study  indicates  a  lesion  of  the  cerebellum,  whereas 
the  ear  examination,  by  giving  additional  data  to  the  neurologist, 
demonstrates  conclusively  that  he  is  dealing  with  a  lesion  of  the 
Ubyrinth. 

A  differential  diagnosis  between  peripheral  and  central  lesions  by 
means  of  the  ear  tests  depends  on  certain  general  principles.    A  pe- 

85 


86  WAR  SURGERY   OF   THE   NERVOUS   SYSTEM. 

ripheral  lesion  of  the  labyrinth  or  VIII  nerve  is  suggested  by  the 
following : 

1.  An  impairment  of  the  function  of  both  the  cochlear  and  kinetic- 
static  labyrinth.  If,  for  example,  the  hearing  tests  show  cochlear  deaf- 
ness and  the  tests  of  the  semicircular  canals  show  that  their  function 
is  also  impaired,  it  immediately  becomes  probable  that  we  are  dealing 
with  an  end-organ  lesion. 

2.  The  history  or  presence  of  tinnitus ;  the  absence  of  tinnitus  does 
not  necessarily  indicate  that  the  end  organ  is  not  involved,  but  its 
presence  is  very  suggestive  of  labyrinth  involvement. 

3.  Proportionate  impairment  of  the  responses  from  the  horizontal 
canal  and  of  the  responses  from  the  vertical  canals.  If  for  example, 
the  tests  show  that  the  horizontal  canal  retains  only  one-half  of  its 
normal  function  and  that  the  vertical  canals  similarly  retain  only  one- 
half  of  their  normal  function,  a  lesion  of  the  end  organ  itself  is  sug- 
gested. 

4.  Proportionate  impairment  of  both  nystagmus  and  vertigo.  If 
the  horizontal  canal  produces  one-third  of  the  normal  nystagmus  and 
one-third  of  the  normal  vertigo,  it  is  suggested  that  the  lesion  is  in 
the  horizontal  canal  itself  or  in  the  fibers  from  the  canal  within  the 
VIII  nerve;  if  in  addition  the  vertical  canals  produce  one-third  of 
the  normal  nystagmus  and  one-third  of  the  normal  vertigo,  an  end- 
organ  lesion  is  strongly  suggested. 

In  a  word  it  is  the  "  proportionate  impairment "  of  responses  that 
speaks  for  a  peripheral  lesion. 

A  central  lesion  is  suggested  by  the  following : 

1.  A  normal  cochlea  but  impaired  or  nonresponsive  semicircular 
canals. 

2.  Normal  responses  from  the  horizontal  canal  but  absent  responses 
from  the  vertical  canals. 

3.  Normal  responses  from  the  vertical  canals  but  impaired  re- 
sponses from  the  horizontal  canal. 

4.  Normal  vertigo  but  impaired  nystagmus  from  the  horizontal 
canal. 

5.  Normal  nystagmus  but  impaired  vertigo  from  the  horizontal 
canal. 

6.  Normal  vertigo  but  impaired  nystagmus  from  the  vertical 
canals. 

7.  Normal  nystagmus  but  impaired  vertigo  from  the  certicafl. 
canals. 

8.  Normal  vertigo  and  normal  nystagmus  from  any  semicircular 
canal,  but  impaired  past  pointing  in  any  direction  of  any  one  ex- 
tremity. 

9.  Normal  vertigo  and  normal  nystagmus  from  any  semicircular 
canal  but  an  impairment  or  absence  of  the  normal  falling. 


VESTIBULAR  APPARATUS.  87 

10.  Spontaneous  vertical  nystagmus  is  pathognomonic  of  a  central 
leison  and  is  indicative  of  involvement  of  the  brain  stem  caused 
either  by  infiltration  or  pressure.  A  lesion  of  the  labyrinth  may  pro- 
duce many  forms  of  spontaneous  nystagmus — horizontal,  rotary, 
oblique  or  a  mixed  nystagmus  of  the  various  types ;  but  an  ear  lesion 
can  never  produce  a  spontaneous  vertical  nystagmus,  either  upward 
or  downward. 

11.  If  there  exists  a  spontaneous  nystagmus  to  the  right  and  non- 
responsive  semicircular  canals  of  the  right  ear,  an  intracranial  lesion 
is  suggested.  The  nonresponsive  labryinth,  if  the  labyrinth  itself 
alone  were  responsible,  would  produce  a  nystagmus  to  the  left. 

12.  A  spontaneous  nystagmus  of  increasing  intensity  or  of  long 
duration  is  indicative  of  a  central  lesion.  A  spontaneous  nystagmus 
due  to  a  lesion  of  the  labyrinth  shows  its  greatest  intensity  at  the 
onset  of  the  disease,  becomes  less  and  less  marked,  and  disappears 
after  a  few  days. 

13.  If  a  stimulation  of  any  semicircular  canal  produces  a  "  per- 
verted "  or  "  inverse  "  nystagmus,  it  is  pathognomonic  of  a  central 
lesion  and  is  indicative  of  a  brain-stem  lesion.  Such  phenomena  as 
the  following  are  frequently  seen: 

Douching  the  right  ear  with  cold  water  with  the  head  back,  stimu- 
lating the  right  horizontal  canal,  should  produce  a  pure  horizontal 
nystagmus  to  the  left.  If  on  such  stimulation  there  occurs  a  vertical 
nystagmus  upward  or  downward,  a  rotary,  oblique,  or  mixed  nystag- 
mus, it  may  be  spoken  of  as  "  perverted."  If  instead  of  a  horizontal 
nystagmus  to  the  left  there  is  produced  a  pure  horizontal  nystagmus 
to  the  right,  it  may  be  termed  an  "  inverse "  nystagmus.  Neither 
a  perverted  nor  an  inverse  nystagmus  can  possibly  be  produced  by 
a  lesion  of  the  labyrinth  or  VIII  nerve ;  a  peripheral  lesion  produces 
a  poor  nystagmus  or  no  nystagmus  at  all,  but  an  absolutely  false 
response  of  necessity  demonstrates  a  central  lesion. 

14.  If  ear  stimulation  produces  a  conjugate  deviation  of  the  eyes 
instead  of  a  nystagmus,  it  is  pathognomonic  of  a  central  lesion. 

The  above  outline  indicates  how  additional  data  may  be  furnished 
to  the  neurologist  by  the  ear  tests  in  determining  whether  he  is  deal- 
ing with  a  lesion  of  the  internal  ear  or  of  the  brain  stem  or  cere- 
bellum. In  the  broader  field  of  intracranial  localization  examination 
of  the  ear  and  of  vestibular  apparatus  is  also  of  distinct  value. 
The  particular  feature  of  the  ear  examination  is  that  the  aurist 
sends  in  a  stirrmlus  to  the  brain  centers,  and  then  notes  the  responses 
of  different  parts  of  the  body  to  this  stimulus.  For  example,  by 
stimulation  of  the  ear  there  results  a  nystagmus  in  a  given  direction, 
a  pointing  of  the  extremities  to  the  right  or  to  the  left,  as  the  case 
may  be,  and  a  falling  to  the  right,  to  the  left,  forward,  or  backward, 
as  the  case  may  be.    Now,  if  the  ear  and  these  central  paths  from  the 


88  WAR  SURGERY   OF   THE    NERVOUS   SYSTEM. 

ear  are  intact,  all  the  normal  responses  will  appear;  if  there  is  a 
failure  of  all  or  any  of  the  responses,  it  is  positive  evidence  of  an 
interruption  along  that  particular  path  or  paths  that  fail  to  bring 
about  these  responses. 

In  order  to  utilize  the  knowledge  obtained  from  these  tests  it  is 
essential  to  have  in  mind  the  various  pathways  constituting  the 
vestibular  apparatus.  It  may  be  stated  at  this  point  in  brief  that 
the  pathways  from  the  horizontal  semicircular  canal  are  different 
after  entering  the  brain  stem  from  those  from  the  vertical  canals; 
furthermore,  that  each  set  of  tracts  divides  into  two  separate  path- 
ways; one  pathway,  the  vestibulo-ocular  tract,  is  responsible  for 
the  eye  movement,  and  the  other  pathway,  the  vestibulo-cerebello- 
cerebral  tract,  conveys  the  impulses  from  the  ear  to  the  cerebral 
cortex,  producing  vertigo.  If  the  horizontal  canal  fails  to  produce 
both  nystagmus  and  vertigo  the  lesion  indicated  is  at  a  point  before 
the  division  of  the  vertical  canal  fibers  into  their  two  separate  path- 
ways. Further,  if  the  horizontal  canal  produces  normal  vertigo  but 
no  nystagmus  the  lesion  indicated  is  of  the  vestibulo-ocular  tract 
at  a  point  beyond  the  point  of  division  into  the  two  paths.  If  the 
horizontal  canal  produces  normal  nystagmus  but  no  vertigo,  the  lesion 
indicated  is  at  a  point  along  the  vestibulo-cerebello-cerebral  path 
beyond  the  point  of  division  into  the  two  pathways.  Similarly,  if 
the  verical  canals  produce  normal  vertigo  but  no  nystagmus,  the 
lesion  indicated  is  in  the  vestibulo-ocular  tract  at  a  point  beyond 
division  into  the  two  paths.  If  the  vertical  canals  produce  normal 
nystagmus  but  no  vertigo,  the  lesion  indicated  is  at  a  point  along 
the  vestibulo-cerebello-cerebral  path  beyond  the  point  of  division  into 
the  two  pathways.  The  ear  tests  have  proven  themselves  surprisingly 
helpful  in  locating  lesions  in  the  cerebello-pontile  angle,  medulla 
oblongata,  pons,  cerebellar  peduncles,  cerebellum,  and  various  por- 
tions of  the  cerebrum,  including  the  parietal  lobe,  the  temporal  lobe, 
and  the  occipital  lobe. 

The  value  of  an  eye  examination  in  neurologic  cases  is  now  uni- 
versally recognized.  The  study  of  the  eye  grounds,  the  field  of 
vision,  pupillary  reaction  to  light  and  accommodation,  and  the  degree 
of  function  of  the  eye  muscles  furnishes  valuable  information  to  the 
neurologist.  Based  on  the  opinion  of  the  neurologists  and  ophthal- 
mologists most  acquainted  with  these  ear  tests  it  would  seem  safe  to 
assert  that  of  the  two  methods  of  approach  very  much  more  definite 
information  can,  as  a  rule,  be  had  from  the  examination  of  the 
vestibular  apparatus  than  from  an  eye  examination.  The  value  of 
ear  examinations  in  neurologic  cases  is  recognized  in  Vienna  to  the 
extent  that  no  examination  of  a  neurologic  case  is  considered  com- 
plete without  a  report  from  the  otologist  as  to  the  condition  of  the 
vestibular  apparatus. 


VESTIBULAR   APPARATUS.  89 

In  order  to  obtain  reliable  data,  from  an  ear  examination  it  is 
essential  that  tlie  technic  of  examination  should  be  accurate  and 
painstaking;  since  it  is  primarily  an  ear  examination  the  otologist 
is  peculiarly  fitted  to  carry  out  such  examination.  Although  one 
purpose  of  this  book  is  to  furnish  a  practical  guide  for  the  otologist 
in  undertaking  the  examination  of  patients,  it  is  also  offered  to  the 
neurologist  so  that  he,  on  his  part,  may  become  familiar  with  the  ear 
aspects  of  the  work,  in  order  to  realize  the  significance  of  the  reac- 
tions as  reported  to  him.  The  ear  examination  is  obviously  not  for 
the  purpose  of  making  a  neurologic  diagnosis ;  it  merely  gives  addi- 
tional information  by  a  series  of  refined  experiments,  to  the  other 
methods  at  the  command  of  the  neurologist.  To  be  sure,  there  are 
many  cases  in  which  the  neurologist,  without  the  aid  of  the  ear,  eje, 
blood,  or  other  examinations,  finds  no  difficulty  in  arriving  at  a  satis- 
factory diagnosis.  In  these  cases,  however,  it  is  of  course  useful  to 
have  the  additional  evidence  from  the  ear  tests  corroborating  his  neu- 
rologic findings.  In  addition  it  not  infrequently  happens  in  obscure 
cases  or  in  cases  in  which  the  neurologic  data  are  meager  that  the 
ear  tests  may  be  the  only  means  of  furnishing  information  upon 
which  a  diagnosis  can  be  made.  For  example,  an  apparently  strong, 
vigorous  man,  complaining  only  of  headache,  showed  on  examination 
that  both  internal  ears  were  normal  and  also  that  both  VIII  nerves 
were  normal,  and  yet  the  vertical  semicircular  canals  of  both  ears, 
when  stimulated,  failed  to  produce  any  responses  whatever.  The 
horizontal  canals  produced  normal  nystagmus,  but  no  vertigo.  As 
the  labyrinths  and  VIII  nerves  in  this  case  were  unquestionably  nor- 
mal the  nonappearance  of  the  normal  responses  to  stimulation 
could  be  accounted  for  only  by  an  interference  with  the  fibers  from 
the  labyrinth  within  the  brain  stem.  This  particular  phenomenon 
complex  indicates  pressure  within  the  IV  ventricle.  This  conclusion 
was  recorded  with  considerable  misgiving  because  a  lesion  within  the 
IV  Ventricle  appeared  ridiculous  in  view  of  the  man's  apparent 
health.  That  night  the  patient  was  rushed  to  the  hospital  uncon- 
scious. The  next  day  he  regained  consciousness,  but  complained 
of  agonizing  headache.  Examination  by  a  number  of  internists  and 
neurologists  failed  to  give  any  clew  of  an  organic  lesion  anywhere, 
and  the  diagnosis  of  hysteria  was  made.  Autopsy  three  days  later 
showed  abscess  in  the  IV  ventricle.  It  is  in  such  cases  as  this  that 
the  ear  examination  is  of  the  utmost  importance,  as  it  gives  data 
absolutely  unattainable  by  the  usual  neurologic  tests. 

THE  EAR  AND  THE  SURGEON. 

The  diagnosis  of  the  precise  location  of  lesions  within  the  cranium 
is  probably  the  most  difficult  task  with  which  the  surgeon  is  con- 
fronted.   Fully  realizing  all  the  difficulties  in  these  cases,  he  utilizes 


90  WAR  SURGERY   OF   THE   NERVOUS  SYSTEM. 

every  modern  aid  in  diagnosis — the  laboratory,  the  X  ray,  or  any 
other  instruments  of  precision  that  may  be  available.  For  many 
years  the  ophthalmologist  has  been  of  great  help  to  the  surgeon 
in  his  intracranial  cases,  and  no  one  would  think  of  operating  on 
such  a  case  without  first  having  the  ophthalmologist's  report  as  to 
his  findings.  The  previous  chapter  has  shown  how  the  ear  tests 
may  furnish  aid  of  value  in  the  accurate  localization  of  lesions 
which  involve  any  of  the  vestibular  pathways,  as  well  as  in  differ- 
entiating between  labyrinth  and  intracranial  lesions.  A  point 
worthy  of  special  emphasis  is  that,  with  the  aid  of  these  tests,  he 
is  frequently  enabled  to  determine  whether  a  lesion  is  operable  or 
inoperable.  Many  lesions  of  the  medulla  oblongata,  pons,  or  cere- 
bellar peduncles,  which  are  inoperable  by  the  very  nature  of  their 
location,  will  show  very  pronounced  cerebellar  symptoms,  and  not 
infrequently  the  cerebellum  is  explored,  in  such  cases,  in  the  hope 
of  finding  a  tumor  near  the  cortex,  and  removing  it.  For  such  a 
differentiation,  in  many  cases,  no  method  can  equal  the  accuracy 
of  the  Barany  tests.  If,  after  turning  and  douching,  there  appears 
a  normal  past  pointing  of  both  extremities  in  both  directions,  it 
may  safely  be  assumed  that  the  cerebellum  itself,  is  intact.  This 
cannot  be  regarded  as  absolutely  final,  but  is  much  more  definite 
than  any  other  known  method  for  determining  the  integrity  of  the 
cerebellum.  It  is  perfectly  conceivable  that  a  case  showing  almost 
normal  past  pointing,  may  apparently  reveal  a  lesion  when  a  cere- 
bellar decompression  is  done.  We  have  seen  two  such  cases.  Here, 
however,  it  should  be  explained  that  in  both  these  instances  the 
lesion  proved  to  be  a  cyst  which  grew  from  the  brain-stem  and  ex- 
tended backward  between  the  cerebellar  hemispheres,  without,  how- 
ever, destroying  the  substance  of  the  cerebellum  itself.  Such  cases 
give  definite  neurologic  evidence  of  a  cerebellar  lesion,  and  at  the 
time  of  operation,  such  a  lesion  is  apparently  discovered.  There 
may  have  been  present  asynergy,  manifested  by  hypertrophy,  adio- 
dokokinesis  and  tremor,  yet  these  symptoms  or  phenomena  were, 
produced  by  involvement  of  the  fibers  on  their  way  to  the  cerebel- 
lum, or  by  pressure  upon  the  cerebellum  itself.  If,  then,  the  ear 
tests  demonstrate  normal  past  pointing,  it  is  strong  evidence  that 
the  cerebellum  itself  is  not  involved. 

Tumors  in  the  cerebello-pontile  angle  either  originate  from  one  of 
the  cranial  nerves  in  the  angle,  usualh'  the  VIII  nerve,  or  have  in- 
vaded the  angle  secondarily  from  the  cerebellum  or  brain  stem. 
These  tumors  invading  the  angle  from  other  adjacent  structures  also 
usually  involve  the  VIII  nerve.  Obviously  then  a  careful  study  of 
the  various  portions  of  the  VIII  nerve  gives  direct  insight  as  to  con- 
ditions in  the  cerebello-pontile  angle.    In  addition,  in  our  experience 


VESTIBULAR  APPARATUS.  91 

the  ear  tests  have  usually  demonstrated  the  two  following  phenomena 
in  cases  of  cerebello-pontile  angle  growth : 

1.  An  absence  of  all  responses  from  the  vei-tical  canal  of  the 
ear  opposite  the  side  of  the  lesion.  Given  a  tumor  in  the  right  cere- 
bello-pontile angle,  the  usual  findings  are  as  follows:  The  right  ear 
gives  no  responses— the  cochlea  shows  absence  of  all  function,  and 
the  horizontal  and  vertical  canals  fail  to  produce  any  nystagmus, 
vertigo,  past  pointing,  or  falling.  The  left  ear  shows  unimpaired 
hearing  and  the  left  horizontal  canal  does  produce  nystagmus, 
vertigo,  past  pointing,  and  falling.  The  left  vertical  canals,  how- 
ever, fail  to  produce  any  responses,  because  the  vertical  canals  fibers 
are  most  probably  impaired  because  of  pressure  upon  the  pons  by 
the  tumor  in  the  angle. 

2.  "  Crossed  past  pointing."  This  phenomenon  consists  of  persist- 
ent past  pointing  of  both  upper  extremities  either  outward  or  in- 
ward, regardless  of  the  type  of  ear  stimulation  employed. 

If  ear  stimulation  produces  normal  n3^stagmus,  vertigo,  past  point- 
ing, and  falling,  the  Barany  tests  are  of  unquestioned  value  in  elimi- 
nating lesions  of  the  posterior  fossa  and  brain  stem.  If  they  rendered 
no  other  service  than  this  it  would  be  sufficient  to  hail  them  as  a 
distinct  contribution  in  the  diagnosis  of  intracranial  lesions.  In 
addition  these  tests  may  prove  helpful  to  the  surgeon  in  preventing 
unnecessary  operations.  One  case  is  of  interest  in  this  connection. 
A  woman  appeared  to  have  a  tumor  of  the  right  cerebellar  hemis- 
phere. This  diagnosis  was  confirmed  by  neurologic  consultants  and 
the  X-ray  report  stated  that  it  was  a  cyst  in  the  right  cerebellar 
hemisphere.  The  ear  tests  suggested  that  the  cerebellum  was  unin- 
volved;  operation  was  delayed  on  this  account  and  eventually  was 
found  to  be  unnecessary,  as  the  patient  steadily  improved  and  was 
discharged  from  the  hospital  .apparently  well,  and  for  years  has 
had  no  recurrence  of  her  symptoms.  Her  cerebellar  symptoms 
evidently  were  due  to  a  disturbance  of  the  internal  ear. 

No  operation  upon  the  brain  should  be  undertaken  without  giving 
the  patient  the  benefit  of  an  ear  examination. 

VESTIBULAR  VEKTIGO. 

Vertigo,  from  whatever  cause,  is  a  subjective  sensation  of  a  dis- 
turbed relationship  to  space.  This  disturbance  is  necessarily  due  to 
an  alteration,  either  stimulating  or  depressing,  of  some  portion  of 
the  vestibular  apparatus.  Inasmuch  as  the  tests  of  the  static  laby- 
rinth disturb  the  vestibular  apparatus,  vertigo  is  necessarily  a  re- 
sulting phenomenon.  It  is  distinctly  a  cerebral  disturbance  resulting 
from  impulses  carried  from  the  ear  to  the  cerebral  cortex.  The 
tracts  producing,  vertigo  run  from  the  ear,  through  the  VIII  nerve. 


92  WAR   SURGES Y   OF   THE    NERVOUS   SYSTEM. 

through  the  brain  stem,  and  through  the  cerebellar  peduncles  as  far 
as  the  cerebellar  nuclei.  There  are  two  separate  afferent  paths  from 
the  ear  to  the  cerebral  cortex,  resulting  in  vertigo  from  ear  stimula- 
tion: (1)  The  horizontal  canal  tracts  and  (2)  the  vertical  canal 
tracts. 

THE  PLANES   OF  VESTIBULAR  VERTIGO. 

The  vestibular  reaction  of  vertigo,  just  like  the  reaction  of  nys- 
tagmus, manifests  itself  in  certain  definite  planes : 

(1)  Sensation  of  turning  in  the  horizontal  plane,  either  from  the 
right  to  the  left  or  from  the  left  to  the  right. 

(2)  Sensation  of  turning  in  the  frontal  plane,  consisting  of  a  sen- 
sation of  falling  to  the  right  or  falling  to  the  left. 

(3)  Sensation  of  turning  in  the  sagittal  plane,  consisting  of  a 
sensation  of  falling  forward  or  backward. 

The  sensation  of  movement  in  the  horizontal  plane  is  produced 
only  by  the  horizontal  canal  or  canals.  This  is  illustrated  by  turning 
the  patient  with  the  head  in  the  upright  position. 

The  sensation  of  turning  in  the  frontal  plane  is  produced  only 
when  the  vertical  canals  are  influenced  in  the  frontal  plane.  When 
the  patient  is  turned  with  the  head  forward  or  backward,  the  plane 
of  the  head  is  frontal. 

Now,  if  after  turning  the  head  is  kept  forward  or!  backward,  the 
subjective  sensation  is  of  turning  in  the  frontal  plane,  which  in  this 
position  of  the  head  is  'parallel  to  the  floor.  The  sensation  is,  there- 
fore, the  same  as  after  turning  with  the  head  upright,  namely,  a 
movement  about  one's  own  axis  either  to  the  right  or  the  left.  As  it 
is  a  sensation  of  turning  in  a  plane  parallel  to  the  floor,  it  is  not 
unpleasant.  If,  however,  after  turning,  the  patient's  head  is  raised 
to  the  upright  position,  the  frontal  plane  then  becomes  at  right  angles 
to  the  floor  and  the  sensation  is  that  of  falling  in  the  frontal  plane 
either  to  the  right  or  to  the  left,  and  is,  therefore,  incidentally  un- 
pleasant. 

The  sensation  of  turning  in  the  sagittal  plane  is  produced  only 
Avhen  the  vertical  canals  are  influenced  in  the  sagittal  plane.  When 
the  patient  is  turned  with  the  head  inclined  well  over  toward  the 
shoulder,  the  plane  of  the  head  is  sagittal.  Now,  if  after  turning 
the  head  is  kept  in  this  same  position  toward  the  shoulder,  the  sub- 
jective sensation  is  of  turning  in  the  sagittal  plane,  which  in  this 
position  of  the  head  is  parallel  to  the  floor.  The  sensation  is,  there- 
fore, the  same  as  after  turning  with  the  head  upright,  namely,  a 
movement  about  one's  own  axis  either  to  the  right  or  to  the  left. 
As  it  is  a  sensation  of  turning  in  a  plane  parallel  to  the  floor,  it  is 
not  unpleasant.  If,  however,  after  turning  the  patient's  head  is 
raised  to  the  upright  position,  the  sagittal  plane  then  becomes  at 


VESTIBULAR  APPARATUS.  93 

right  angles  to  the  floor  and  the  sensation  is  tliat  of  falling  in  the 
sagittal  plane ;  this  consists  of  a  feeling  of  pitching  forward  or  back- 
M'ard,  and  is,  therefore,  incidentally  unpleasant. 

In  speaking  of  this  unpleasantness  resulting  from  endolymph 
movement  in  the  vertical  plane,  we  may  use  the  illustration  of  sea- 
sickness. Barany  calls  attention  to  the  fact  that  a  ship  at  sea  tosses 
in  various  planes: 

(1)  The  horizontal  plane,  from  right  to  left.  This  movement, 
however,  is  usually  very  slight  and,  unfortunately,  as  we  have  al-, 
ready  shown,  this  is  the  only  plane  of  movement  that  is  not  un- 
pleasant. 

(2)  The  frontal  plane — ^namely,  a  rolling  of  the  ship  from  side 
to  side.  If  the  individual  is  standing  facing  the  bow  of  the  ship, 
the  vertical  canals  are  affected  in  the  frontal  plane.  This  is  un- 
pleasant. If,  therefore,  the  individual  lies  down  with  his  head  or 
his  feet  toward  the  bow,  the  rolling  movement  then  affects  his  hori- 
zontal canals,  and  the  unpleasantness  disappears. 

(3)  The  sagittal  plane — namely,  a  pitching  of  the  ship  fore  and 
aft.  If  the  individual  is  standing  facing  the  bow  of  the  ship,  the 
vertical  canals  are  affected  in  the  sagittal  plane.    This  is  unpleasant. 

If,  therefore,  the  person  lies  down  with  the  line  of  the  body  extend- 
ing across  the  ship  from  starboard  to  post,  the  pitching  movement 
then  affects  the  horizontal  canals,  and  the  unpleasantness  disappears. 

The  up-and-down  movement  of  the  ship,  rising  and  sinking,  in  a 
similar  way  affects  the  vertical  canals  when  the  individual  is  in  the 
upright  position.  The  unpleasantness  caused  by  this  movement  is 
also  relieved  when  the  individual  lies  down,  as  then  the  up-and- 
down  movement  affects  the  horizontal  canals,  the  stimulation  of 
which  is  so  much  less  unpleasant. 

Unfortunately  the  movements  of  the  ship  at  any  given  time  are 
seldom  in  one  plane  only.  If  it  were  not  for  this,  these  suggestions 
of  Barany  would  unquestionably  prove  of  great  relief  to  the  seasick. 
Even  as  it  is  we  have  the  explanation  of  the  fact  that  a  seasick  in- 
dividual feels  much  better  when  he  lies  down. 

THE  ARTIFICIAL  PRODUCTION  OF  VESTIBULAR  VERTIGO. 

The  subjective  sensation  of  vertigo  after  ear  stimulation  is  due 
to  the  movement  in  one  direction  or  the  other  of  the  hair  cells  of 
the  end  organ  in  the  labyrinth;  such  sensations  can  be  produced 
either  by  turning  an  individual  in  a  revolving  chair  or  by  douch- 
ing the  ears. 

Vertigo  after  turning. — If  a  person  is  turned  with  the  head  upright 
toward  the  right,  with  eyes  closed,  his  first  sensation  is  of  turning 
toward  the  right.     This  is  due  to  the  lagging  behind  of  the  endo- 


94  WAE,  SUEGEE.Y   OF   THE   IsTERVOUS   SYSTEM. 

lymph  in  the  horizontal  semicircular  canals.    Diagrammatically  this 
can  be  represented  as  follows: 

Endolymph  lags  behind. 
Canal. 


Now,  as  the  turning  is  continued  the  endolymph  catches  up  to 
the  movement  of  the  body  and  the  individual  no  longer  feels  that 
he  is  turning,  although  actually  he  is  turning. 

Endolymph. 


Canal. 

On  stopping  the  chair  the  endolymph  continues  to  move,  and  the 
person  has  a  sensation  of  turning  in  the  opposite  direction,  namely, 
to  the  left,  although  he  is  actually  sitting  absolutely  quiet  in  the 
chair. 

Endolymph. 

Canal 


The  essential  feature  of  the  subjective  sensation  of  vertigo  after 
turning  is  that  after  turning  to  the  right  the  individual  feels  he  is 
turning  to  the  left,  regardless  of  the  position  of  the  head.  After 
turning  to  the  right  wdth  the  head  forward,  or  after  turning  to 
the  right  with  the  head  backward,  although  the  movement  of  the 
endolymph  is  in  a  diametrically  opposite  direction,  the  result  is  the 
same — namely,  a  subjective  sensation  of  turning  to  the  left.  It  will 
be  recalled  that  this  is  not  true  of  nystagmus.  Turning  to  the  right 
with  ths  head  forward  produces  nj^stagmus  to  the  left;  turning  to 
the  right  with  the  head  backward  produces  nystagmus  to  the  right. 
This  is  because  nystagmus  is  a  simple  reflex,  depending  directly  on 
the  direction  of  the  endolymph  movement.  Vertigo,  on  the  other 
hand,  is  a  cerebral  phenomenon;  in  determining  the  interpretation 
of  the  sensation  of  movement,  the  cerebrum  takes  into  consideration 
the  position  of  the  head.,  and  in  this  way  properly  interprets  the 
significance  of  the  endolymph  movement  with  the  head  in  any  given 
position. 

The  following  is  a  table  of  the  subjective  sensations  of  vertigo 
produced  by  turning : 

Turning  to  the  right  with  the  head  upright  produces  a  sensation  of 
movement  to  the  left  in  the  horizontal  plane. 


VESTIBULAR  APPARATUS.  95 

Turning  to  the  left  with  the  head  in  the  uprij>;ht  position  produces 
a  sensation  of  turning  to  the  right  in  the  horizontal  plane. 

Turning  to  the  right  with  the  head  forward  120°  produces — 

(a)  With  the  head  kept  in  the  forward  position,  a  sensation  of 
turning  to  the  left  in  the  horizontal  plane. 

(h)  With  the  head  brought  upright,  a  sensation  of  falling  to  the 
left  in  the  frontal  plane. 

Turning  to  the  left  with  the  head  forward  120°  produces — 

(a)  With  the  head  kept  in  the  forward  position,  a  sensation  of 
turning  to  the  right  in  the  horizontal  plane. 

(&)  Bringing  the  head  to  the  upright  position,  a  sensation  of  fall- 
ing to  the  right  in  the  frontal  plane. 

Turning  to  the  right  with  the  head  back  60°  produces — 

(a)  With  the  head  kept  in  this  backward  position,  a  sensation  of 
turning  to  the  left  in  the  horizontal  plane. 

(b)  With  the  head  brought  upright,  a  sensation  of  falling  to  the 
left  in  the  frontal  plane. 

Turning  to  the  left,  head  back  60°  produces — 

(a)  With  the  head  kept  in  this  backward  position,  a  sensation  of 
turning  to  the  right  in  the  horizontal  plane. 

(&)  Head  brought  to  upright  position,  a  sensation  of  falling  tc 
the  right  in  the  frontal  plane. 

It  is  not  necessary  to  memorize  all  the  subjective  sensations  of 
turning.  In  the  chapter  on  nystagmus  it  is  noted  that  the  eyes  are 
always  drawn  in  the  direction  of  the  endolymph  movement.  As 
regards  the  subjective  sensation  of  systematized  vertigo,  the  follow- 
ing rules  should  be  remembered :  Vertigo  is  always  in  the  direction 
opposite  to  the  endolymph  movement. 

Experience  by  sight  and  muscle  sense  has  taught  the  individual 
that  when  he  turns  to  the  right  and  the  endolymph  is  lagging  behind, 
that  he  is  turning  to  the  right.  When  he  stops  and  the  endolymph 
continues  to  go  to  the  right,  he  therefore  has  a  subjective  sensation 
of  turning  to  the  left.  The  original  basis  for  his  mental  interpre- 
tation of  the  endolymph  is  that  when  he  turns  to  the  right  the  endo- 
lymph moves  relatively  to  the  left.  The  mental  interpretation,  there- 
fore, is  always  of  a  subjective  sensation  of  movement  in  a  direction 
opposite  to  the  endolymph  current. 

Vertigo  after  douching. — On  douching  the  ear  with  either  cold  or 
hot  water,  after  a  sufficient  time  has  elapsed  to  permit  of  chilling 
of  the  outer  wall  of  the  labyrinth,  there  occurs  a  systematized  vestib- 
ular vertigo.  The  following  is  a  table  of  the  subjective  sensations 
of  vertigo  produced  by  the  caloric  test. 

Douching  the  right  ear,  head  upright,  water  68°,  produces  sensa- 
tion of  falling  to  the  left  in  the  frontal  plane. 


96  .  WAR   SURGERY    OF    THE    NERVOUS   SYSTEM. 

Douching  the  left  ear  with  the  head  upright,  water  68°,  produces 
sensation  of  falling  to  the  right  in  the  frontal  plane. 

Douching  the  right  ear  with  the  head  120°  forward,  water  68°, 
produces  sensation  of  falling  to  the  left  in  the  frontal  plane. 

Douching  the  left  ear  with  the  head  120°  forward,  w^ater  120°, 
produces  sensation  of  falling  to  the  right  in  the  frontal  plane. 

Douching  the  right  ear^  head  back  60°,  water  68°,  produces  sen- 
sation of  falling  to  the  left  in  the  frontal  plane. 

Douching  the  left  ear,  head  back  60°,  water  68°,  produces  sen- 
sation of  falling  to  the  right  in  the  frontal  plane. 

Douching  the  right  ear,  head  upright,  water  112°,  produces  sen- 
sation of  falling  to  the  right  in  the  frontal  plane. 

Douching  the  right  ear,  head  back  60°,  water  112°.  produces  sen- 
sation of  falling  to  the  right  in  the  frontal  plane. 

Douching  the  left  ear,  head  back  60°,  water  112°,  produces  sen- 
sation of  falling  to  the  left  in  the  frontal  plane. 

Douching  the  right  ear,  head  forward  120°,  water  112°,  produces 
sensation  of  falling  to  the  left  in  the  frontal  plane. 

Douching  the  left  ear,  head  forward  120°,  water  112°,  produces 
sensation  of  falling  to  the  right  in  the  frontal  plane. 

THE  TECHNIC  OF  EXAMINATION  OF  THE  STATIC  LABYRINTH. 

(By  Isaac  H.   .Jones,  M.   D.,  and  Lewis   Fisher,   M.  D.     Annals  of   Otology, 
Rhinology,  and  Laryngology,  March,  1917. 

So  little  has  been  known  of  the  physiology  of  the  static  labyrinth 
until  comparatively  recent  times,  that  the  lack  of  a  well-established 
technic  of  its  examination  is  not  surprising.  The  value  of  the  con- 
tributions of  Ewald,  Hogjes,  Von  Stein,  Alexander,  Naumann,  Sham- 
baugh,  E.  R.  Lewis,  J.  G.  Wilson,  Ruttin,  and  others  is  now,  how- 
ever, beginning  to  receive  the  recognition  it  deserves.  By  far  the 
greatest  impetus  to  this  work  was  given  by  Robert  Barany,  who  in 
the  last  decade  brought  out  the  "  caloric  ''  and  "  pointing ''  tests — 
contributions  which  brought  him  the  Nobel  prize.  With  these  tests 
came  the  realization  of  the  intimate  relation  of  the  internal  ear  to 
the  rest  of  the  central  nervous  system.  We  know  now  that  the  static 
labyrinth  is  only  the  labyrinth  of  the  vestibular  apparatus — this 
vestibular  apparatus  consisting  of  the  static  portion  of  the  internal 
•ear  and  nerve  paths  connecting  it  with  nerve  centers  in  the  brain 
stem,  cerrebellum,  and  cerebrum. 

Originally  tests  of  the  labyrinth  were  carried  out  for  the  sole 
purpose  of  determining  its  own  integrity.  Such  tests  were  sufficient 
for  the  aural  surgeon  who  Avas  called  upon  to  decide  whether  or  not 
to  operate  on  the  "  end  organ."  With  the  development  of  the  idea 
that  the  labyrinth  is  only  one  portion  of  the  vestibular  apparatus, 


VESTIBULAR  APPARATUS.  97 

came  the  realization  tliat  this  whole  apparatus  was  being  tested  at 
the  same  time  that  the  internal  ear  itself  was  being  tested,  and  that 
an  intelligent  interpi'etnti<5n  of  the  phenomena  obtained  by  such  tests 
can  also  give  the  examiner  an  insight  into  the  condition  of  those 
various  brain  paths  and  brain  centers  in  relation  with  the  internal 
ear.  Thus,  when  a  known  stimulus  is  applied  to  the  labyrinth,  any 
response  obtained  therefrom,  be  it  nystagmus  or  vertigo,  indicates  nol 
(mly  a  functi(mating  and  reacting  labyrinth,  but  also  intact  path- 
ways from  the  iabyrintii  to  the  brain  centers  responsible  for  those 
reactions.  Conversely,  the  nonappearance  of  any  of  the  normal  re- 
sponses to  stimvdation  indicates  an  interruption  at  some  point  along 
the  particular  pathway  that  fails  to  produce  that  particular  response. 
This  made  it  evident  that  the  old  technic  of  examination  of  the  static 
labyrinth  was  very  inadequate,  and  Baranj-  elaborated  a  new  technic. 
Kecent  investigations  by  writers  in  the  department  of  neurootology 
at  the  University  of  Penns3dvania,  under  the  service  of  Dr.  B.  Alex- 
imder  Randall,  have  shown  that  the  fibers  from  the  so-called  liorizon- 
tal  semicircular  canal  ha^e  an  entirely  separate  course  in  the  brain 
stem  from  those  of  the  vertical  semicircular  canals,  and  while  they  all 
go  to  the  cerebellum.  Ave  consider  that  those  from  the  horizontal 
<;anal  reach  it  by  way  of  the  inferior  cerebellar  peduncle,  while  those 
I'rom  the  vertical  canals  go  by  way  of  the  middle  cerebellar  peduncle. 
Barany's  technic,  elaborated  before  such  a  differentiation  was  demon- 
strated, deals  with  the  labyrinth  as  a  whole,  whereas  in  the  light  of 
this  new  knowledge,  it  at  once  becomes  evident  how  important  it  is 
to  examine  each  set  of  canals  separately. 

We  also  became  convinced  that  nystagTQus  and  vertigo  are  distinct 
and  separate  phenomena,  and  that,  furthermore,  the  "  past  pointing  " 
of  Baniny  is  not  a  ''  cerebellar  pull,''  but  is  a  cerebral  phenomenon 
exclusively  and  depends  entirely  on  the  vertigo  induced  by  the  ear 
stimulation.  This  again  necessitated  the  modification  of  some  of  the 
vxisting  tests  as  Avell  as  the  employment  of  some  new  ones.  Above 
all  it  is  of  prime  importance  that  the  technic  be  accurate,  com- 
plete, and  painstaking,  if  the  data  obtained  from  such  an  examina- 
tion are  to  be  relied  on.  We  would  suggest  that  those  who  appear 
to  be  doubtful  of  the  value  of  these  tests  must  ascribe  their  clisap- 
j/ointment  to  laxity  in  methods  of  conducting  them.  This  point  has 
loeen  im])ressed  on  us  by  the  statement  of  one  of  the  leading  men  in 
the  profession,  who  claims  that  the  "  Barany  tests''  had  been 
routinely  employed  in  his  cases  and  proved  of  no  value.  We  found 
that  he  had  used  no  turning  chair.  Another  authority  reported  a 
case  in  which  there  was  an  absence  of  the  normal  past  pointing,  and 
yet  o])eration  revealed  a  normal  cerebellum.  We  found  that  this 
physician  did  have  a  turning  chair,  but  that  it  was  not  equipped  witii 
a  ••  sto]:)  pedal:''  we  ha^e  frequently  seen  cases  examined  without  a 
1.3764—17 7 


98  WAE    SURGEEY    OF    THE    NEEVOUS    SYSTEM. 

stop  pedal  in  which  no  past  pointing  was  obtained,  and  on  testing 
them  with  our  chair  with  the  stop  pedah  we  Avere  able  to  produce 
past  pointing  of  a  foot  or  more. 

The  technic  about  to  be  described  has  been  employed  in  the  ex- 
amination of  hundreds  of  cases,  and  the  deductions  drawn  from 
them  have  been  verified  in  many  instances  by  operations  and  au- 
topsies. 

When  we  first  began  examinations  of  the  static  labj-rinth,  a  great 
difficulty  was  encountered  in  the  recording  of  the  findings,  or  rather 
in  the  lack  of  recording  them.  All  who  have  done  this  work  realize 
what  an  unspeakable  nuisance  it  is  to  keep  haphazard  records,  on 
slips  of  paper,  perhaps,  of  the  results  obtained  from  the  various 
vestibular  tests.  For  example :  "  On  turning  to  the  right  the  pa- 
tient's nystagmus  was  horizontal  to  the  left  of  so  many  seconds,  but 
his  past  pointing  was  so  much  for  the  right  arm  to  the  right,  and  so 
much  for  the  left  arm  to  the  right,"  etc.  We  all  know  how  hope- 
less it  is  to  attempt  the  analysis  of  a  case  from  such  records.  To 
obviate  this  difficult}^  we  graduall}^  formulated  the  accompanying- 
chart,  in  which  all  the  tests  are  outlined  in  the  order  in  which  they 
are  usually  undertaken  and  which  is  so  arranged  that  when  properlj^ 
filled  in  it  shows  all  the  vestibular  data  simply  by  a  glance  at  one 
page.  We  think  this  chart  is  of  so  much  help  in  the  examination  and 
diagnosis  of  a  case  that  it  is  actuallj^  a  part  of  the  technic,  and  we 
will,  therefore,  describe  it. 

One  side  of  the  chart  is  devoted  to  miscellaneous  details  or  such 
routine  matters  as  are  found  on  any  chart,  with  particular  emphasis 
on  the  examination  of  the  cochlea.  The  other  side  is  devoted  exclu- 
sively to  the  vestibular  tests,  of  which  there  are  three  divisions,  as 
follows : 

1.  Spontaneous. 

2.  Turning. 

3.  Caloric. 

There  is  a  complete  column  for  the  "  nystagmus,"  and  another 
complete  column  for  "  pointing."  This  enables  us  to  study  the  nys- 
tagmus as  such  by  running  the  eye  down  the  colmnn  to  the  left, 
showing  first  the  spontaneous  n3^stagmus,  then  the  nystagmus  after 
turning,  and  then  after  the  caloric  test.  In  the  same  Avay  the  pointing 
tests  can  be  studied  as  such  by  following  right  down  the  page,  first 
the  spontaneous,  then  those  after  turning,  and  then  after  douching. 

As  a  further  aid  there  is  a  space  reserved  on  the  chart  for  sum- 
marizing the  findings  obtained  after  each  form  of  examination.  As 
we  always  look  for  the  following  phenomena — nystagmus,  vertigo, 
past-pointing,  and  falling — they  are  indicated  concisely,  one  under- 
neath the  other,  in  each  one  of  the  three  subdivisions.  The  examiner, 
after  he  has  turned  the  patient,  simply  summarizes  by  indicating 


VESTIBULAR    APPARATUS.  99 

■'  nystagmus  normal ''  or  "  absent "' ;  vertigo,  either  *'  normal ''  or 
■'  subnormal,''  or  ""  exaggerated  "  or  '*  absent,''  as  the  case  may  be,  and 
so  on  in  the  same  way  under  the  other  headings.  When  the  chart  is 
filled  in  as  we  have  indicated,  and  an  analysis  of  the  case  attempted 
for  the  purpose  of  diagnosis,  all  the  examiner  need  do  is  to  look  at 
these  different  summaries  under  the  three  main  subdivisions  to  get  a 
bird's-eye  sdew,  as  it  were,  of  the  whole  case. 

We  will  imagine  Ave  are  examining  a  patient  and  conducting  the 
tests  step  by  step,  with  the  aid  of  the  chart.  The  "  miscellaneous 
side  "  of  the  chart  is  filled  in  first,  taking  up  every  heading  indicated 
and  filling  it  in  with  appropriate  information — the  name,  the  age, 
and  so  on,  with  emphasis  on  the  history  of  dizziness,  for  the  reason 
that  there  can  be  no  impairment  of  the  vestibular  apparatus  without 
dizziness  as  a  symptom.  The  duration  of  the  dizziness,  its  character, 
when  it  was  first  noticed,  whether  it  came  on  gradually  or  suddenly, 
A\'liether  the  attacks  came  on  with  sudden  change  of  position — as,  for 
example,  on  getting  out  of  bed  in  the  morning,  or  when  washing  the 
face — whether  nausea  or  vomiting  accompanied  it — all  are  noted. 

Staggering.— Did  it  come  on  suddenly  or  gradually  ?  Is  it  constant 
or  does  it  come  on  intermittently?  Is  its  presence  coincident  with 
dizziness  ?  Is  it  at  any  time  severe  enough  to  make  the  patient  fall  ? 
If  staggering  and  falling  are  present,  is  it  always  in  the  same  direc- 
tion? 

Tinnitus. — The  presence  or  absence  of  tinnitus  is  of  considerable 
importance,  since  it  might  be  an  aid  in  the  differential  diagnosis 
between  peripheral  and  central  lesions.  We  wonld  expect  tinnitus 
to  be  present  in  affections  of  the  labyrinth  itself  or  in  lesions  of  the 
so-called  "  end-organ  "  type,  whereas  it  would  be  more  likely  to  be 
absent  in  those  disturbances  of  the  vestibular  apparatus  located 
within  the  brain. 

Deafness. — Its  duration,  and  whether  the  loss  of  hearing  was  grad- 
ual or  sudden,  are  noted. 

Nose  and  throat. — A  routine  examination  is  made  with  a  view  of 
discovering  some  evidence  of  focal  infection  which  might  account 
for  the  presence  of  an  irritative  disturbance  of  the  vestibular  appa- 
ratus, should  the  rest  of  the  examination  point  that  way;  also,  for 
any  abnormality  which  might  throw  some  light  on  any  possible  intra- 
cranial condition,  such  as  palsies  of  the  tongue,  pharynx,  or  vocal 
cords,  anesthesias,  or  loss  of  the  sense  of  taste  or  smell. 

THE  EAR. 

We  note  the  folloAving: 

1.  Configuration  of  the  auditory  canals. 

2.  The  presence  or  absence  of  a  mechanical  obstruction  in  the 
canals,  congenital  or  acquired ;  of  the  latter  there  may  be  impacted 
cerumen  or  other  debris  or  polypi. 


100  WAH  SURGERY   OF   THE    NERVOUS   SYSTEM. 

3.  The  presence  of  inflammation  or  suppuration. 

4.  Condition  of  the  tympanic  membrane.  The  length  of  time 
necessary  to  douche  before  a  reaction  appears  may  depend  in  a 
measure  on  the  thickness  of  the  drumhead.  Perforations  are  looked 
for,  since  a  "  dry  perforation "  would  be  a  contraindication  to 
douching. 

5.  Hearing  function.  This  is  of  the  utmost  importance  in  all 
cases,  because  a  knoAvledge  of  the  condition  of  the  cochlear  labyrinth 
is  frequently  of  the  greatest  help  in  the  differentiation  between  an 
"  intracranial  ■"  and  an  "  end-organ  "  lesion.  The  cochlea  is  philo- 
genetically  the  younger  and  newer  portion  of  the  labyrinth,  and, 
therefore,  the  weaker  and  less  resistant  to  the  action  of  toxins.  A 
perfectly  functionating  cochlea  would,  therefore,  per  se,  presuppose 
a  normal  static  labyrinth. 

The  fistula  test. — ^This  is  performed  only  in  cases  where  there  is 
a  chronic  suppuration  of  the  ear  and  can  be  carried  out  with  the  use 
of  the  Politzer  bag. 

We  are  now^  ready  for  the  vestibular  tests,  all  of  them  being  out- 
lined on  the  "  vestibular  "  side  of  the  chart. 

SPONTANEOUS  PHENOMENA. 
NYSTAGMUS. 

The  patient  is  instructed  to  look  straight  ahead  of  him  at  a  dis- 
tant point,  as  the  effort  at  convergence  v,'hen  looking  at  a  near  object 
may  obscure  the  findings  to  the  extent  of  limiting  or  entirely  effacing 
a  nvstagmus.  The  use  of  convex  lenses  serves  three  purposes :  First, 
convergence  is  entirely  impossible;  second,  the  observer  is  able  to 
view  the  eyes  from  in  front ;  and  third,  the  eyes  are  now  much  mag- 
nified. A  spontaneous  nystagmus  of  any  form  on  looking  straight 
ahead  is  always  pathologic.  The  patient  is  then  told  to  look  to  the 
extreme  right  and  the  extreme  left.  With  an  unintelligent  patient 
this  test  is  accomplished  more  easily  by  placing  him  in  the  revolving 
chair  and  have  him  fix  his  eyes  on  some  distant  point.  The  chair  is 
then  turned,  first  to  the  left  and  then  to  the  right.  In  this  way  we 
revolve  the  body,  as  it  were,  around  the  eyes.  A  certain  amount  of 
lateral  nystagmus,  when  looking  to  the  extreme  right  or  extreme 
left,  is  physiologic.  It  is  pathologic  only  when  it  is  of  considerable 
amplitude  or  when  there  is  a  sharp  difference  between  the  nystagmus 
on  looking  to  the  right  and  on  looking  to  the  left.  All  forms  of 
nvstagmus  become  more  pronounced  when  the  individual  attempts 
to  look  in  the  direction  of  the  nystagmus.  It  is  for  this  reason  that 
the  subject  is  made  to  look  in  various  directions,  as  by  so  doing  we 
are  often  able  to  bring  out  a  pathologic  nystagmus  of  an  amplitude 


VESTIBULAR   APFAEATUS.  101 

not  large  enough  to  become  evident  on  looking  ^^traight  ahead. 
Nystagmus  is  recorded  by  means  (jf  an  arrow — a  straight  one  for 
horizontal  nystagmus  and  a  curved  one  for  the  rotary:  it  seems 
simpler,  as  suggested  to  us  by  George  Mackenzie,  to  lune  the  ai'row 
point  in  the  direction  in  which  the  examiner  sees  the  nystagmus  on 
the  patient.  With  eyelids  held  wide  apart,  the  patient  is  told  t(» 
look  directly  upward  and  then  downward,  with  a  \iew  of  disco\er- 
ing  a  vertical  nystagmus,  if  present.  This  is  of  the  utmost  impor- 
tance for  the  reason  that,  as  Barany  has  pointed  (Jut,  a  spontaneous 
vertical  nystagmus  is  invariably  intracranial  in  origin;  furthermore, 
in  our  exj^erience  a  spontaneous  vertical  nystagmus  has  pro\  en  itself 
to  be  a  pathognomonic  symptom  of  involvement  of  the  brain  stenj 
either  by  pressure  or  infiltration.  If  a  vertical  nystagmus  is  present 
it  is  recorded^ — the  arrow  pointing  either  up  or  down,  as  the  case 
may  be.  Paresis  or  paralysis  of  any  of  the  ocular  muscles,  as  well 
as  the  ability  to  perform  conjugate  movements  of  both  eyes,  are 
noted. 

SPONTANEOITS     VERTIGO. 

The  patient  is  asked  not  merely  whether  he  is  ''  dizzy,"  but  whether, 
he  has  any  sensation  of  turning.  If  the  latter  is  present,  careful 
inquir}?^  is  made  whether  or  not  the  turning  is  systematized.  By 
systematized  vertigo  is  meant : 

1.  The  patient  feels  he  is  going  in  a  certain  direction. 

2.  The  outside  world  is  moving  in  a  certain  direction  around  him, 
but  he  himself  is  remaining  still. 

3.  He  himself  is  moving  in  one  direction,  and  the  world  about  him 
is  moving  in  the  opposite  direction. 

SPONTANEOUS    POINTING. 

The  patient  sits  in  the  chair  and  is  told  to  put  his  arm  forward 
and  point  with  his  forefinger.  The  examiner  holds  out  his  own  fore- 
finger, and  allows  that  of  the  patient  to  come  in  contact  with  his. 
The  examiner  steadies  his  arm  against  his  owai  body  and  further 
steadies  his  outstretched  forefinger  by  means  of  the  other  hand.  The 
patient's  forefinger  is  allowed  to  come  in  contact  with  the  examin- 
er's finger,  after  which  the  patient  raises  his  arm,  without  bending, 
the  elbow,  to  the  perpendicular  position,  and  immediately  brings  it 
back  to  touch  the  examiner's  finger.  He  is  then  directed  to  repeat 
this  with  his  eyes  closed.  Should  the  patient  find  the  finger,  it  is 
recorded  under  the  column  for  pointing  for  the  appropriate  arm  with 
a  letter  "  T"  (touched).  Should  he  deviate  either  to  the  right  or  the 
left,  the  test  is  repeated  a  number  of  times  to  make  sure  that  the 
failure  is  not  the  result  of  pure  inattention,  but  that  the  deviation  is 
constant  and  persistent  in  a  certain  direction.     The  distance  of  the 


102  WAK   SURGERY   OF    THE    ISTEEVOUS   SYSTEM, 

deviation  is  recorded  in  inches,  either  to  the  right  or  to  the  left, 
as  the  case  may  be.  by  noting  nnder  the  appropriate  pointing  col- 
umn-— let  us  say  "  2  to  R.,"  if  the  deA^iation  happens  to  be  2  inches 
to  the  right,  or  "2  to  L.,"  if  the  deviation  happens  to  be  to  the 
left.  etc.  Should  the  patient  fail  to  find  the  finger  and  "  past 
point "  either  to  the  right  or  to  the  left,  his  arm  must  never  be  pulled 
over  toward  the  examiner's  finger  if  the  test  is  to  be  repeated,  be- 
cause if  this  is  done  the  patient  finds  out  that  he  "  past  pomted,"' 
and  might  make  a  conscious  correction  to  overcome  an  actual  tend- 
ency to  past  point."  Instead,  the  examiner  should  again  place  his 
ovsn  finger  under  that  of  the  patient.  In  taking  the  pointing,  it  is 
usually  sufficient  to  test  the  pointing  of  the  shoulder  joint  "  from 
above,""  as  described ;  the  other  forms  of  pointing,  such  as  "  shoulder 
from  below,"  or  "  shoulder  from  the  side,"  or  pointing  of  the  hips, 
are  not  performed  routinely — these  are  undertaken  only  in  cases 
where  such  extensive  examinations  appear  to  be  necessary. 

SPOIS^TANEOUS    FALLING. 

The  Romberg  test. — The  patient  is  told  to  stand  with  heels  and  toes 
together  and  eyes  closed.  His  station  is  noted.  While  in  this  posi- 
tion the  head  is  quickly  turned  to  the  right,  and  observation  made 
Avhether  that  had  any  effect  upon  the  "  station  "  or  upon  the  direction 
of  the  patient's  "  falling,"  should  he  have  any.  The  same  observation 
is  made  after  the  head  is  quickly  turned  to  the  left.  This  test  is  of 
value  in  that  patients  with  intracranial  lesions  ahvays  fall  in  the 
same  direction,  regardless  of  the  position  of  the  head,  whereas  a 
labj^rinthine  lesion  causes  falling  in  the  direction  of  the  affected  ear. 

"  The  attempt  to  overthrow." — This  is  Barany's  own  "  pelvic  girdle 
test."  The  individual  stands  as  before,  with  eyes  closed,  heels  and 
toes  together.  The  examiner  grasps  the  patient  at  both  shoulders. 
and  attempts  to  overthrow  him  either  to  the  right  or  the  left,  forward 
or  backward,  instructing  the  patient  all  the  while  to  resist  this  at- 
tempt at  overthrowing  by  a  balancing  movement  at  the  hips.  When 
the  shoulders  of  the  patient  are  moved  toward  the  right,  the  pelvis 
should  sway  toward  the  left  in  an  attempt  to  maintain  equilibrium. 
On  pushing  the  patient  backward,  the  pelvis  should  move  forward, 
and  so  on.  In  this  way  the  degree  of  freedom  of  pelvic  movement 
is  observed.  A  normal  individual  balances  perfectly,  and  lean  in 
Mny  of  the  four  directions  considerably  before  falling,  whereas  in 
one  with  an  affection  of  the  vermis  of  the  cerebellum,  the  pelvis 
fails  to  compensate,  and  the  patient  falls  over  like  a  broomstick  at 
the  slightest  touch. 

Goniometer. — This  consists  of  a  movable  platform  so  arranged  that 
it  can  be  tilted  out  of  the  horizontal  plane.    One  end  of  the  platform 


VESTIBUI.AR    APPARATUS.  103 

luis  !i  cord  attached  to  it  by  means  of  whicli  that  end  can  he  pulled 
<h)\vii — the'  otlier  end  rising-  against  a  graduated  perpendicular 
column.  The  ])atient  stands  in  the  center  of  this  platform,  either 
facing  the  examiner  or  at  right  angles  to  him.  He  is  first  tested  with 
eyes  open.  One  end  of  the  platform  is  gradually  lowered  by  pulling 
on  the  cord  until  the  patient  Ijegins  to  sway,  showing  that  he  is 
about  to  lose  his  equilibrium.  The  other  (perpendicular  and  gradu- 
ated) end  shows  the  number  of  degrees  of  tilting  that  were  necessary 
before  the  patient  began  to  lose  his  equilibrium.  He  is  then  tested 
in  the  same  way  witl)  eyes  closed.  By  means  of  the  goninometer  it  is 
sometimes  possible  to  bring  out  a  latent  tendency  to  fall  not  demon- 
strable in  any  other  way.     This  is  onl}'  occasionally  useful. 

Having  completed  the  examinations  for  the  various  spontaneous 
phenomena,  we  are  now  ready  to  examine  the  vestibular  apparatus 
by  means  of  the  tui'ning  and  caloric  tests.  In  order  to  carry  out  a 
good  technic,  it  is  Avell  to  bear  in  mind  the  whys  and  wherefores  of 
the  various  tests.  Both  the  turning  and  caloric  tests  depend  upon  the 
.setting  in  motion  of  the  lymph  within  the  labyrinth.  This  circula- 
tion of  the  lymph  stimulates  the  hair  cells  in  the  ampullee  of  the 
semicircular  canals,  starting  impulses  which  are  transmitted  by  nerve 
paths  to  the  corresponding  centers  in  the  grain.  The  principle 
underlying  these  tests  is  that  a  known  stimulus  applied  to  a  normal 
labyrinth  will  produce  definite  phenomena  if  the  nerve  paths  from 
such  a  normal  labyrinth  to  their  centers  are  all  intact. 

Before  drawing  conclusions,  therefore,  we  must  be  certain  of  our 
technic,  we  must  make  sure  that  the  proper  stimulus  was  applied, 
and  must  forever  bear  in  mind  the  particular  nerve  path  we  are 
emjiloying  in  a  given  test.  The  following  points  should  be  remem- 
bered : 

( 1 )  The  desirability  of  testing  only  one  set  of  canals  at  a  time. 

(•2)  In  the  turning  chair  we  test  only  those  canals  which  are  in 
the  horizontal  plane,  or  rather  those  out  of  the  absolutely  vertical 
plane. 

(o)  The  caloric  test  alt'ects  only  those  canals  which  are  in  the 
vertical  plane,  or  rather  those  wdiich  are  out  of  the  horizontal  plane. 

(4-)  Each  canal,  wh.en  stimulated,  produces  a  nystagmus  and  a 
vertigo  in  its  own  plane. 

(5)  The  eyes  are  always  drawn  in  the  direction  of  the  endo- 
lymph  movement  (this  is  the  slow  component). 

(G)  The  vertigo  is  always  in  the  direction  opposite  to.  the  endo- 
lymph  movement. 

The  individual  is  placed  in  a  smoothly  revohing  chair  which  has 
an  adjustable  headpiece,  so  that  the  head  can  be  comfortably  fixed 
and  held  in  any  desired  position.  The  chair  must  also  have  a  mecha- 
nism whereby  it  can  be  instantly  stopped  by  means  of  a  foot  pedal 


104  WAE    SURGEEY   OF   THE    NERVOUS   SYSTEM. 

in  a  given  position  and  rigidity  held  there.  Without  such  an  ar- 
rangement past-pointing  tests  can  not  be  made  accurately.  Biirany 
constructed  a  special  chair  for  this  purpose,  and  we  were  fortunate 
enough  to  receive  one  of  these  chairs  only  a  few  days  before  the  out- 
break of  the  war  in  Europe.  As  it  was  hardly  probable  that  any 
more  of  these  chairs  could  come  out  of  Vienna  for  some  time,  several 
physicians  interested  in  the  work  asked  us  to  design  a  chair  along- 
similar  lines.  After  we  had  used  the  Barany  chair  for  several  months 
the  following  changes  suggested  themselves  and  were  incorporated  in 
the  new  chair. 

(1)  The  back  of  the  chair  and  the  headrest  are  so  constructed 
that  the  patient's  head  is  placed  immediately  over  the  axis  of  turn- 
ing. This  is  obviously  of  great  importance.  In  the  original  Barany 
chair  the  head  revolves  away  from  the  center  of  turning,  and  de- 
scribes a  circle  with  a  diameter  of  over  a  foot. 

(2)  It  is  impossible  in  the  Barany  chair  to  hold  the  head  in  a  for- 
ward position.  We  therefore  constructed  an  extra  headpiece  to 
permit  rotation  with  the  head  inclined  forward.  It  is  obvious  that 
it  is  absolutely  essential  for  the  head  to  be  held  steady  when  being 
rotated  in  this  position,  and  this  can  not  be  accomplished  without  a 
special  head  bracket. 

(3)  Instead  of  having  a  special  handle  for  turning,  as  in  the 
Barany  chair,  the  rod  at  the  back  of  the  chair  is  made  slightly  longer 
and  a  handle  placed  at  the  top.  The  extra  handle  was  very  annoying 
and  interfered  with  the  pointing  tests  of  the  right  arm  by  its  presence 
on  the  side  of  the  chair. 

(4)  The  base  is  made  much  heavier  than  in  the  Baranj^  chair,  in 
order  that  the  patient  may  be  rotated  rapidly,  if  necessary,  and  yet 
not  have  the  chair  wobble ;  this  gives  both  the  patient  and  the  doctor 
a  greater  sense  of  security. 

(5)  The  Barany  chair  is  bound  together  by  a  great  many  bolts. 
In  order  to  take  the  chair  apart,  in  case  it  is  desired  to  move  it,  all 
these  bolts  must  be  undone.  In  the  new  chair  there  are  no  bolts  and 
the  parts  are  all  welded;  the  chair  consists  of  only  two  pieces — the 
seat  and  the  base.  This  makes  it  more  portable,  and  is  a  great  con- 
venience when  a  patient  has  to  be  examined  at  a  place  where  no  such 
chair  can  be  had.  In  constructing  this  chair  we  also  aimed  to  make 
it  suitable  for  use  as  a  regular  office  treatment  and  operating  chair,  so 
that  it  would  not  require  any  extra  room  in  the  office. 

TURNING. 

The  routine  method  is  to  test  first  for  nystagmus,  then  for  vertigo, 
and  then  for  past-pointing.  The  horizontal  canals  are  tested  in  the 
turning  chair.    To  accomplish  this  the  head  must  be  secured  in  the 


VESTIBULAR    APPARATUS.  105 

headrest;  tilted  30  degrees  forAvard — the  reason  being  that  with  tlie 
head  perfectly  erect,  the  external  or  so-called  horizontal  semicircular 
canal  slants  30  degrees  backward.  If  this  precaution  is  neglected,  the 
vertical  canals  also  enter  into  the  reactions. 

NYSTAGMUS  AFTER  TURNING. 

During  the  turning  the  patient's  eyes  are  closed.  The  chair  is 
rotated  to  the  right  10  times,  at  the  speed  of  2  seconds  to  each 
turn,  making  20  seconds  for  the  10  turns,  after  which  it  is  stopped. 
The  patient  is  told  to  open  his  e^^es  and  look  otf'  at  a  distance.  The 
"  after-turning "  nystagmus  is  then  noted,  including  its  direction, 
character,  and  duration.  The  time  of  the  nystagmus  is' best  taken 
with  a  stop  watch,  the  watch  being  clicked  and  time  counted  fi-om 
the  moment  the  chair  is  stopped  until  the  very  last  nystagmus  twitch 
disappears,  when  it  is  clicked  again  and  the  number  of  seconds  read 
off.  It  is  recorded  with  a  horizontal  arrow  pointing  in  the  proper 
direction  after  the  words  ''to  right"  on  the  chart.  The  amplitude 
is  recorded  in  terms  of  either  "  large,"  "  small,"  "  fair,"  or  "  barely 
a  twitch."  The  duration  is  recorded  in  seconds  as  read  off  from  the 
watch.    In  a  normal  case  this  nystagmus  should  be  2G  seconds. 

In  a  similar  manner  the  patient  is  turned  to  the  left. 

The  employment  of  the  stop  pedal  is  not  necessary  in  testing  foi 

VERTIGO    AFTER    TURNING. 

Vertigo  after  turning  may  be  tested  quantitatively.  The  plane 
of  the  induced  vertigo  is  always  in  the  plane  of  the  canal  stimulated 
and  in  a  direction  opposite  to  the  enclolymph  movement.  If  it  is  the 
horizontal  canals  we  wish  to  test,  the  patient's  head  must  be  fixed 
with  the  chin  tilted  30  degrees  forward.  He  is  then  turned,  with 
eyes  closed,  to  the  right  at  a  uniform  speed,  and  is  asked  to  keep  on 
telling  the  examiner  in  what  direction  he  is  being  turned.  Thus  he 
keeps  on  saying  "  to  the  right,  to  the  right.''  After  10  turns  in  10 
seconds  the  chair  is  stopped  and  immediately  he  will  say,  "  I  am 
going  to  the  left."  The  stop  watch  is  started  the  same  instant  and 
kept  running  as  long  as  the  patient  thinks  he  is  going  to  the  left. 
"V\nien  he  says,  "  I  am  standing  still,"  the  watch  is  stopped  and  the 
reading  of  the  duration  of  the  vertigo  taken  in  seconds.  In  a  nor- 
mal case  the  duration  of  the  vertigo  is  approximately  24  seconds. 

The  test  is  performed  in  a  similar  way  by  turning  the  patient  to 
the  left. 

This  quantitative  test  for  vertigo  is  not  necessary  as  a  routine 
procedure.  "  Past  pointing,"  which  we  are  about  to  discuss  and 
which  is  routinely  tested,  makes  this  unnecessary.  When  the  pa- 
tient is  turned  to  the  right  and  stopped,  he  feels  that  he  is  turning 


106  WAR   SURGERY    OF    THE    N"ERVOUS   SYSTEM. 

to  the  left,  and  for  this  reason  he  "  past  points  "  to  the  right.  That 
is,  when  the  patient  is  stopped  after  being  turned  in  the  chair,  he  has 
a  subjective  sensation  of  turning  in  a  direction  opposite  to  that  in 
which  he  Avas  actually  turned.  After  touching  the  examiner's  finger 
at  this  time,  he  is  under  the  impression  as  he  is  raising  his  arm  that 
he  is  turning  away  from  the  finger,  and  therefore  tries  to  correct 
for  that  by  moA-ing  the  arm  out  to  the  point  where  he  conceives  the 
finger  now  to  be.  Since  as  a  matter  of  fact  he  is  not  moving,  the 
chair  being  held  rigidly  still,  he  points  widely  past  the  finger  and 
continues  doing  so  in  lessening  degree  as  long  as  the  vertigo  lasts. 
The  very  presence,  therefore,  of  past  pointing  is  indicative  of  the 
presence  of  vertigo — the  past  pointing  being  the  objective  evidence  of 
his  subjective  impression  of  turning. 

PAST  poi>;ting  after  turning. 

The  patient's  head  is  again  fixed  so  that  the  horizontal  canals 
only  are  tested,  and  the  chair  turned  at  double  the  speed  of  that  for 
nystagmus — that  is,  the  10  turns  are  made  in  10  seconds  instead  of 
20.  The  patient  is  carefully  instructed  as  to  what  is  expected  of 
him,  and  is  told  to  keep  his  eyes  closed  throughout  the  entire  test. 
The  examiner  stands  in  front  of  the  patient  with  the  stop  pedal  near 
his  right  foot.  As  the  chair  is  turned  for  the  tenth  time  the  pedal 
is  released  by  the  examiner's  right  foot  and  the  speed  of  the  chair 
gradually  slackened,  so  that  the  stop  is  accomplished  without  any  jar- 
ring. The  patient's  right  hand  is  then  quickly  grasped,  and  after 
his  forefinger  touches  the  examiner's  finger,  the  examiner  says,  "  up." 
upon  which  the  jjatient  raises  the  arm  in  question  to  the  perpen- 
dicular and  immediately  tries  to  come  back  to  the  examiner's  finger. 
The  "  past  pointing  "  is  called  off  in  inches  and  recorded  by  the  assist- 
ant where  it  says  "  shoulder  from  above,"  as,  for  instance,  "  15  to  R." 
(15  inches  to  the  right).  The  left  arm  is  immediately  tested  in  the 
same  way,  then  the  right  arm  again,  then  the  left  arm  again,  and  so 
on  until  there  is  no  longer^  anv  past  pointing.  In  a  normal  case  the 
vertigo  lasts  sufficiently  long  to  permit  of  three  past  pointings  of  each 
arm,  gradually  lessening  in  extent  until  the  patient  is  again  able  to 
find  the  fingei'. 

The  patient  is  then  turned  to  the  left  and  the  past-pointing  of 
both  arms  taken  and  recorded  as  above. 

The  patient's  eyes  must  be  kept  closed  throughout  these  tests,  and 
if  his  cooperation  is  doubtful  it  is  best  to  blindfold  him. 

The  turning  tests  affect  only  those  semicircular  canals  which  are 
in  a  horizontal  plane  while  the  patient  is  turned.  Should  it  be 
desired  to  test  the  two  sets  of  vertical  canals  by  turning,  the  patient's 
head  must  be  placed  either  120°  forward  or  60°  backward.  For 
turning  with  the  head  forward,  a  small  bar  with  a  comfortable  head- 


VESTIBULAR    APPARATUS.  10^ 

rest  is  placed  between  the  two  iirnis  of  the  turning'  chaii'  and  the 
patient  turned  ten  times,  first  to  the  right.  The  i-esulting  nystagnnis 
and  vertigo  are,  of  course,  in  the  frontal  phine — a  rotary  nystagmus 
to  the  left  and  A'ertigo  to  the  left. 

In  taking  the  past  pointing  the  ])atient  keeps  his  head  in  the  same 
position  after  stopping  the  chair,  and  the  examiner  is  forced  to  kneel 
on  the  floor  in  making  the  test.  The  past  pointing  is  not  so  large 
as  that  obtained  from  the  horizontal  canals,  but  is  with  both  arms 
to  the  right  after  turning  to  the  right,  and  with  Vioth  arms  to  the 
left  after  turning  to  the  left. 

When  testing  the  vertical  canals  with  the  head  back,  the  uprights 
or  turning,  handle  is  loosened  at  the  ratchet  and  turned  back.  The 
headrest  is  brought  all  the  way  doAvn  and  the  head  comfortably 
fixed  in  a  position  60°  backward.  The  patient  is  turned  to  the  right, 
and  there  is  produced  a  rotary  nystagmus  to  the  right  (just  the 
opposite  to  that  obtained  from  turning  with  the  head  forward). 
The  past  pointing,  however,  is  also  to  the  right,  just  the  same  as 
that  obtained  after  turning  to  the  right  with  the  head  upright  or 
with  the  head  forward.  It  may  be  remarked  in  passing  that  this 
test  does  not  bear  out  the  statement  and  law  laid  down  in  all  the 
writings  on  this  subject,  including  Barany 's,  that  "  the  past  pointing 
is  always  in  the  direction  opposite  to  that  of  the  nystagmus."  Nys- 
tagmus and  vertigo  (Avith  its  consequent  past  pointing)  are  not  in 
any  way  dependent  on  each  other.  They  are  different  reactions  pro- 
duced by  stimuli  sent  along  entirely  different  paths.  A  normal 
individual  always  past  points  to  the  right  after  having  turned  to 
the  right,  regardless  of  the  position  of  the  head.  Nystagmus,  on 
the  other  hand,  is  in  a  diametrically  opposite  direction,  after  turning 
with  the  head  backward  from  what  it  is  on  turning  with  the  head 
forward.  Turning  to  the  right  with  the  head  back  produces  a  nys- 
tagmus to  the  right  and  a  past  pointing  to  the  right,  so  that  the 
statement  that  "  past  pointing  in  a  direction  opposite  to  the  nystag- 
mus "'  is  not  only  misleading  and  confusing,  but  actually  incorrect. 

FALLING  AFTER  TURNIN(i. 

This  results  when  the  individual  tested  has  a  subjective  sensation 
of  turning  in  a  vertical  plane.  He  will  fall  to  the  right  or  left  if  he 
thinks  he  is  turning  in  a  frontal  plane,  and  will  fall  forward  or  back- 
ward if  he  thinks  he  is  turning  in  a  sagittal  plane.  Therefore,  turn- 
ing a  patient  with  the  head  tilted  30  degrees  forward  produces  no 
falling,  as  the  patient  feels  he  is  revolving  in  a  plane  parallel  to  the 
floor.  Similarly,  turning  with  the  head  forward  or  backward  pro- 
duces no  falling  so  long  as  the  head  is  maintained  in  this  position. 
If.  however,  after  turning  with  the  head  forward  or  backward,  the 


108  WAR  SUEGEEY   OF   THE    NEEVOUS   SYSTEM, 

head  is  brought  to  the  upright  position,  the  subjective  sensation  is 
now  one  of  turning  in  a  plane  at  right  angles  to  the  floor,  and  the 
patient  falls  either  to  the  right  or  left.  Again,  if  the  head  is  inclined 
toward  the  shoulder,  after  the  turning  the  subjective  sensation  is  one 
of  turning  in  a  plane  parallel  to  the  floor ;  if  the  head  be  raised  to  the 
upright  position,  however,  the  subjective  sensation  is  that  of  turning^ 
in  a  sagittal  plane,  and  the  patient  falls  forward  or  backward.  These 
tests,  however,  are  seldom  necessar}^  in  routine  examination. 

CALORIC  TEST. 

The  main  advantage  of  the  caloric  test  of  Barany  is  that  it  enables 
us  to  examine  each  internal  ear  separately,  and  also  to  analyze  the 
function  of  its  canals  separately,  Avhereas  turning  stimulates  both 
labyrinths  at  the  same  time.  It  is  essential  to  have  an  absolute 
standard  in  the  matter  of  temperature  of  the  water.  As  Barany 
directs,  we  employ  water  at  68°  F.  This  temperature  is  sufficiently 
cool  to  secure  a  good  reaction,  and  yet  not  cold  enough  to  be  uncom- 
fortable to  the  patient.  When  hot  water  is  to  be  used  the  tempera- 
ture is  112°  F.    The  latter  should  be  but  seldom  used. 

The  vessel  containing  the  water  is  placed  about  2  feet  above  the 
level  of  the  ear  to  be  douched.  The  shape  or  size  of  the  nozzle  is  im- 
material, the  essential  thing  being  that  a  free  and  continuous  stream 
of  water  shall  flow  against  the  drum  membrane  maintaining  an  eA^en 
temperature  of  68°.  The  nozzle  has  a  closing  valve  within  easy 
reach  of  the  fingers.  This  valve  also  enables  the  examiner  to  regu- 
late the  force  and  volume  of  the  stream  of  water  entering  the  canal. 
A  rubber  receptacle  is  placed  imderneath  the  patient's  ear  to  catch 
the  return  flow  of  the  water.  A  tube  at  the  bottom  conducts  the 
water  into  a  basin  below.  When  this  is  properly  attached  there  is 
little  chance  of  Avetting  the  patient,  and  if  necessary  douching  can 
be  kept  up  for  several  minutes  Avithout  any  interruption. 

Eemembering  the  desirability  of  testing  only  one  set  of  canals  at 
a  time,  and  recalling  still  further  that  this  caloric  test  influences  onlj^ 
those  canals  Avhich  are  in  a  vertical  plane,  the  patient's  head  is  placed 
30°  forAvard  so  as  not  to  include  the  horizontal  canal  in  the  re- 
action. The  chair  is  held  firmly  by  the  foot  clamp,  the  stop  watch 
is  held  ready,  the  nozzle  is  inserted  into  the  canal,  and  the  instant  at 
Avhich  douching  is  started  the  stop  Avatch  is  clicked.  The  patient's 
eyelid  is  elevated;  the  patient  is  asked  to  look  down  and  the  eyeball 
carefully  Avatched  for  any  rhythmic  nystagmus  to  appear.  The  mo- 
ment that  a  rotary  ryhthmic  nystagmus  appears  the  stop  Avatch  is 
clicked  again  and  the  number  of  seconds  necessary  to  produce  the  re- 
action noted.  We  usually  continue  the  douching  for  a  fcAv  seconds 
longer  in  order  to  obtain  the  maximum  reaction.  In  the  normal, 
nystagmus  appears  after  40  seconds,  and  after  douching  for  5  or 
10  seconds  more  shoAvs  a  large  amplitude.     The  direction  of  the 


VESTIBULAR  APPARATUS.  109 

nystagmus  is  recorded  by  a  curved  arrow  on  the  chart  where  it  says 
'"  douche  right."  The  amplitude  is  noted  beneath  and  then  the 
length  of  time  required  to  produce  it. 

The  patient  is  then  told  to  close  his  eyes  and  the  pointing  tests 
are  carried  out  and  recorded  in  the  same  Avay  as  before  described.  It 
is  well  to  remember  that  this  douching  has  produced  vertigo  in  the 
frontal  plane — the  same  reaction  that  occurs  after  turning  with  the 
head  forward ;  the  patient,  therefore,  exhibits  a  marked  tendency  to 
fall,  and  it  is  advisable  to  have  an  assistant  hold  the  patient's  head 
firmly  in  the  head  rest  while  taking  the  pointing  tests.  As  soon  as 
the  past  pointing  of  the  arms  has  been  taken  the  head  is  (juickly 
tilted  to  a  position  60°  back,  which  places  the  horizontal  canal 
in  the  vertical  plane  in  a  position  in  which  it  can  be  affected  by 
the  chilling.  The  patient  is  told  to  look  upward,  and  the  existing 
rotary  nystagmus  immediatelj'  becomes  horizontal.  The  pointing  of 
both  arms  is  then  quickly  taken  with  the  head  in  that  position.  The 
head  may  then  be  tilted  forward  90°.  and  the  past  pointing  of 
both  arms  be  taken  again.  This  new  position  of  the  head  again 
influences  the  horizontal  canal,  but  has  reversed  the  direction  of  the 
endolymph  mo\ement.  All  the  reactions,  therefore,  are  also  reversed. 
The  duration  of  the  average  stimulus  after  douching  is  long  enough 
to  permit  of  the  examination  of  the  head  in  the  three  positions  just 
given.  It  is  well  to  note  that  in  this  way  one  douching  of  onlj^  one 
ear  can  test  out  all  the  pathways  for  nystagmus  as  well  as  produce 
past  pointing  in  all  directions,  enabling  us  to  test  out  the  integrity  of 
the  entire  cerebellum. 

Falling. — The  caloric  test  by  its  very  nature  produces  vertigo 
only  in  a  plane  at  right  angles  to  the  floor,  so  that  "falling'"  always 
occurs  on  douching  a  normal  ear.  All  that  is  routinely  necessary  is 
to  observe  the  tendency  to  fall  while  the  other  examinations  are 
going  on.  and  to  note  it  on  the  chart. 

ELECTRICAL. 

For  practical  purposes  the  electrical  tests  have  been  of  only  slight 
use  in  our  experience.  Since  the  ability  to  examine  one  set  of  canals 
at  a  time  is  of  such  prime  importance  in  making  these  tests  of  great 
clinical  usefulness,  it  is  evident  how  limited  are  the  uses  of  ati 
agency  which  stimulates  at  the  same  time  not  only  the  entire  laby- 
I'inth.  but  the  eighth  nerve  as  well,  and  perhaps  even  the  medullary 
nuclei.  It  is  of  great  use,  however,  when  the  question  arises  as  to  a 
differential  diagnosis  between  a  destruction  of  the  labyrinth  and  the 
eighth  nerve.  In  a  recent  destruction  of  the  labyrinth  the  caloric 
test  will  produce  no  reactions.  The  electric  current,  however,  may 
directly  aflf'ect  the  eighth  nerve  and  produce  normal  reactions.    When 


110  WAR    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 

the  galvanic  current  is  used  a  large  electrode  is  held  in  one  hand, 
and  a  small  one  is  placed  on  the  mastoid  process.  Both  electrodes 
should  be  covered  with  cloth  or  cotton  fairly  saturated  with  a  nor- 
mal salt  solution.  The  current  is  gradually  turned  on,  and  when 
four  milliamperes  are  discharged  a  nystagmus  should  appear. 

It  must  not  be  thought  that  a  routine  examination  of  the  internal 
ear  requires  all  the  preceding  tests.  In  order  to  illustrate  the  sim- 
plicity of  a  complete  average  examination  of  the  static  labyrinth  we 
insert  a  chart  properly  filled  in  with  the  results  of  the  examination 
of  a  normal  individual.  Naturally,  for  example,  if  douching  the 
vertical  canals  of  both  ears  gives  a  doubtful  response,  it  is  wise  to 
verify  the  examination  by  turning  with  the  head  back — or  forward: 
in  this  case  the  findings  are  recorded  on  an  extra  chart  to  avoid  con- 
fusion. In  the  average  case,  however,  it  is  necessary  merely  to  fill 
out  one  vestibular  page,  as  shown,  and  to  conduct  all  the  tests  with 
the  head  upright ;  the  turning  in  this  position  tests  the  horizontal 
canals,  and  the  douching  examines  the  vertical  canals.  The  exami- 
ner needs  merely  to  complete  this  chart  to  have  before  him  all  the 
essential  data  of  a  routine  examination. 


Part  4. 

ABSTRACTS  FROM  WAR  LITERATURE  OF  HEAD 
INJURIES. 

ENGLISH  SCHOOL. 

A  survey  of  the  recent  literature  of  the  war,  as  the  subjoined  ex- 
tracts show,  demonstrates  what  has  been  said  in  the  preface,  nanielj^, 
that  exigencies  of  time,  place,  and  circumstance  modify  the  funda- 
mental (we  might  almost  call  them  orthodox)  principles  laid  doAvn 
by  Gushing.  These  variations  are  best  appreciated  in  gross  by 
grouping  the  literature  under  the  heads  of  English,  French,  and 
(xerman.  As  might  naturally  be  expected,  however,  there  are  vari- 
ations of  opinions  even  in  the  ranks  of  these  three  schools. 

Wilfred  Trotter,  for  many  years  an  enthusiastic  "worker  in  the 
field  of  neurological  surgery,  correlates  fundamental  facts  with  les- 
sons learned  in  the  Avar  zone : 

Trotter,  W.:  The  Principles  of  the  Operative  Treatment  of  Trau- 
matic Cerebral  Lesions.    Brit.  J.  Surg.,  1915,  ii,  520. 

The  article  itself  is  divided  into  four  sections,  with  many 
subdivisions,  all  of  which  tend  to  bring  out  the  correlation 
referred  to  above. 

Under  the  heading,  "  Physiological  peculiarities  of  the 
cerebral  circulation,"  a  short  anatomical  description  of  the 
brain  is  given,  with  special  stress  on  the  absolute  inelasticity 
of  the  craniodural  capsule  and  the  close  application  of 
this  capsule  to  the  brain.  These  facts  are  used  in  the  sec- 
tions on  encroachments  on  the  intracranial  cavity. 

1.  Of  encroachments  of  vital  origin,  hemorrhage  is  the 
chief.  The  effects  noted  are  due  solely  to  an  interference 
with  the  circulation  in  that  part  of  the  brain  affected : 
(1)  Stage  of  compensation:  With  a  developing  hematoma, 
space  is  afforded  for  the  blood,  without  impairing  cerebral 
circulation,  (a)  by  a  displacement  of  the  cerebrospinal 
fluid,  and  (h)  by  compression  of  the  regional  veins,  which 
allow  of  a  certain  amount  of  compression  before  conges- 
tion. (2)  Stage  of  venous  obstruction:  As  hemorrhage  in- 
creases, the  comi:)ression  on  the  veins  also  increases  until 
they  are  finally  obliterated,  causing  a  congestion  and  cy- 
anosis of  the  brain  in  that  region.  In  many  cases  of  trau- 
matic compression  the  process  goes  no  further  and  gives 
]-ise  merely  to  an  increased  excitability  of  cerebral  tissue. 
(8)  Stage  of  anemia:  Further  increase  in  the  hematoma 
leads  to  a  collapse  of  the  capillaries,  and  a  white  area  is 

ill 


112  WAR    SUEGEEY   OF    THE    NERVOUS   SYSTEM. 

formed  immediately  beneath  the  clot,  from  which  the  blood 
is  totally  squeezed  out.  This  gives  rise  to  paralytic  symp- 
toms, which  condition  is  invariable  and  characteristic.  If 
the  hemorrhage  continues,  these  areas  gradually  enlarge 
until  more  and  more  brain  substance  is  involved,  with  cor- 
responding symptoms — the  three  zones  of  compression,  how- 
ever, maintaining  their  entities. 

Encroachments  due  to  external  violence  fall  under  the 
heads  of  (1)  deformation  of  the  skull  through  external 
violence,  as  a  fall  on  the  head,  and  (2)  traversing  of  the 
skull  by  high-velocity  bullet.  The  physical  consequences 
of  both  are  identical.  At  the  moment  of  in]\ny  there  is  a 
very  great  increase  of  intracranial  tension,  and  the  entire 
brain  is  subjected  to  hyperacute  compression.  This  gives 
rise  to  total,  but  momentary,  capillary  anenda  of  the  brain, 
with  resultant  widespread  paralytic  symptoms,  and  is  known 
as  concussion  of  the  brain.  It  is  characterized  by  («)  in- 
stantaneous onset;  (6)  paralytic  symptoms  referable  to  all 
parts  of  the  brain;  (e)  tendency  to  spontaneous  recovery; 
and  (d)  absence  at  post-mortem  of  any  characteristic 
findings. 

1.  In  injuries  accompanying  deformation  of  the  skull,  as 
a  rule,  there  is  an  inbending  of  the  skull,  but  no  depressed 
fracture.  Part  of  the  force  being  transmitted  throughout 
the  cavity  causes  concussion  and  part  directh^  ail'ects  the 
brain  substance.  The  brain  is  injured  (1)  at  the  point  of 
impact  of  skull  and  brain,  direct  contusion;  (2)  diametri- 
cally opposite- — contrecoup  or  polar  contusion;  and  (3)  be- 
tween these  two  points,  in  scattered  foci — substance  contu- 
sion. Also  the  sudden  displacement  of  cerebrospinal  fluid 
in  the  ventricles  mnj  cause  foci  of  contusion  through  the 
narrower  parts,  the  Sylvian  aqueduct. 

2.  Injuries  due  to  transit  of  a  bullet  depend  on  the  ve- 
locity of  the  bullet.  At  maximum  velocity,  the  cranial  con- 
tents acting  as  continuous  homogeneous  medium,  the  skull 
is  shattered,  the  scalp  torn  open,  and  the  brain  disorganized. 
At  slightly  less  velocity  the  scalp  remains  whole,  but  the 
brain  and  skull  are  destroyed.  As  velocity  declines,  this 
explosive  effect  is  the  first  to  disappear,  except  at  the  exit 
wound.  At  low  velocities  there  is  intense  hj^peracute  com- 
pression of  the  brain,  an  explosive  efl^ect  at  the  exit  wound ; 
but  as  long  as  the  cranial  vault  remains  intact,  extensive 
destruction  of  the  brain  does  not  occur. 

3.  Injuries  associated  Avith  localized  fracture  are  essen- 
tially local.  The  scalp  is  lacerated,  the  skull  conmiinuted 
and  depressed,  and  the  brain  contused  or  lacerated  locally, 
Avith  no  scattered  or  distant  foci  of  indirect  injury,  no 
polar  contusion,  and  slight  con(;ussion.  There  are  three 
practical  rules  in  these  cases;  (7)  In  adults^  hi'variably  all 
depressed  fractures  are  compound.  (2)  The  damage  to  the 
hrain  is  often  underestimated.  (3)  The  prognosis  is  hei- 
fer than  the  wound  would  indicate,  because  there  is  no  polar 
contusion  or  distant  lesions. 


FOEEIGN    WAR    LITEEATUR?:.  113 

There  are  t]iree  modes  of  action  of  cerebral  injuries  as 
follows : 

1.  Direct  destructive  effects. — Most  commonly  by  bullets, 
and  easily  recognized. 

2.  Reactionary  swelling. — Injury  of  the  brain  leads  to 
edema  and  swelling,  which  in  turn  leads  to  pressure  on  the 
veins  and  venous  obstruction;  but  there  is  no  capillary 
anemia,  and  the  symptoms  are  chiefly  confined  to  the  irrita- 
tive phenomena.  It  is  when  this  condition  progresses  below 
the  tentorium  into  the  vital  centers  that  the  gravest  effects 
are  produced.  In  concussion  of  the  brain  the  irritative 
symptoms  coming  on  several  hours  after  injury  are  due  to 
this  reactionary  edema  causing  venous  obstruction,  and  a 
purel}^  clecompres.sive  operation  is  indicated, 

3.  Hemorrhage. — This  is  the  most  important  mechanism 
by  which  symptoms  are  produced  after  head  injuries.  The 
situation  has  an  important  effect  on  the  size  of  the  hema- 
toma, and  the  rate  of  bleeding  is  even  more  important,  con- 
sidering the  symptoms  and  the  gravity  of  the  case. 

(a)  Eoi'trachu'dl. — Found  chiefly  in  the  middle  fossa  and 
usually  from  the  middle  meningeal  artery:  may  come  from 
the  veins  and  may  be  located  in  the  frontal  region. 

{h)  Subdural. — Commonest  cause  of  severe  compression. 
In  the  acute,  the  hemorrhage  readily  and  rapidly  extends 
over  the  whole  hemisphere,  which  is  displaced  toward  the 
opposite  side.  It  may  spread  to  the  posterior  fossae  and 
bulbar  symptoms  occur.  The  pressure  often  forces  the  brain 
into  the  tentorial  foramen,  preventing  the  spread  into  the 
inferior  fossa  and  subsequent  bulbar  involvement. 

{c)  Cortical. — Arises  from  the  vessels  of  the  cortex  and  is 
the  most  conmion  cause  of  Jacksonian  epileps}'.  It  is  the 
result  of  cerebral  contusion. 

{d)  Intracerebral. — Is  very  uncommon  and  very  grave.  Is 
due  to  severe  cerebral  contusion  from  one  of  the  distant  foci 
of  injury  in  the  brain  substance,  is  accompanied  by  other 
contusions,  and  usually  without  fracture  of  the  skull. 

((?)  Intracerdr'icidar. — Is  usually  an  extension  of  the  in- 
tracerebral into  the  ventricle  and  is  very  uncommon. 

Clinical  types  of  cerebral  injury  are  as  folloAvs: 

1.  Grave  and  extensive  hemispheral  compression. — After 
severe  injury  concussion  develops,  which  passes  off,  followed 
by  a  lucid  interval,  and  then  a  comatose  state,  with  hemi- 
spheric signs.  Progressing  pupillary  changes  occur  and, 
later,  irritative  bulbar  symptoms.  Operation  is  indicated, 
the  opening  to  be  made  in  the  temporal  fossa  and  to  be  small. 
If  the  brain  bulges  strongly,  a  decompression  is  necessarj^ 
The  dura  should  always  be  incised  to  discover  a  concealed 
hematoma  and  it  should  not  be  sutured  afterwards.  Drain- 
age usually  is  not  necessary. 

2.  Grave  injury  without  localizing  signs. — After  severe  in- 
jury with  fracture  of  the  base  and  external  hemorrhages, 
concussion  occurs,  and  shades  into  more  or  less  complete 
coma  without  a  distinct  interval.    Usually  this  coma  is  not 

1.3764—17 8 


114  WAR   SUEGEEY   OF    THE    NERVOUS   SYSTEM. 

profound.  There  is  some  rigidity  of  the  limbs;  reflexes  are 
exalted  or  depressed;  there  is  no  definite  pupillary  change 
and  no  incomplete  bulbar  signs.  Such  a  case,  if  of  severe 
grade,  is  usually  fatal,  but  milder  conditions  often  recover 
spontaneously.  They  are  prone  to  pneumonia  and  menin- 
gitis, however.  No  direct  treatment-  is  indicated,  because 
there  is  no  definite  focal  lesion.  If  coma  becomes  profound 
and  persistent  for  days  or  weeks,  that  in  itself  localizes  the 
pressure  in  the  superior  chamber  and  indicates  a  temporal 
decompression  operation.  The  results  are  usually  satis- 
factory. 

3.  Cases  with  mainly  irritative  signs. —  (a)  Severe  head  in- 
juries ivith  mental  excitement.  From  a  state  of  concussion 
the  case  passes  into  a  violent,  uncontrollable  delirium,  as  if 
fighting  drunk.  A  diagnosis  is  often  impossible  immedi- 
ately, and  usually  only  after  observation.  Generally  this 
delirium  is  more  impenetrable  to  external  influences  and 
signs  of  severe  headache  are  present.  As  a  rule,  it  is  nec- 
essary to  delay  operation  until  some  definite  paralytic  phe- 
nomenon appears. 

{h)  Classical '"'' cerebral  irritation.''-  After  concussion  has 
passed,  a  typical  state  of  cerebral  irritation  supervenes.  The 
case  is  very  irritable,  pulse  usually  quick,  temperature  raised, 
and  always  a  severe  headache.  There  is  no  mental  confusion, 
but  no  spontaneous  eifort,  mental  or  physical.  Occasionally, 
however,  there  is  delirium,  especially  at  night.  This  is  a 
condition  of  moderate  venous  congestion  with  edema,  caused 
by  multiple  foci  of  contusion  through  brain  substance. 
Spontaneous  recovery  is  usual,  but  is  generally  followed  by 
headache,  giddiness,  loss  of  memory,  and  even  epilepsy.  If 
severe,  temporal  decompression  is  indicated. 

4.  Cases  v/ith  signs  of  localized  lesion. — These  are  mainly 
cases  of  cortical  hemorrhage  after  direct  or  polar  contusion. 
Symptoms  of  localized  cerebral  irritation  usually  show  after 
several  days  or  a  week,  and  are  most  common  in  the  motor 
area.  Operation  should  be  performed  as  soon  as  localiza- 
tion of  the  hematoma  can  be  made. 

5.  Compound  depressed  fracture. — There  is  a  remarkable  ab- 
sence of  symptoms  of  concussion  or  distant  injury,  and  the 
prognosis  is  surprisingl}^  good.  The  diagnosis  is  usually 
easy,  but  a  skiagram  should  always  be  taken.  Unless  the  in- 
jury has  directly  affected  some  part,  there  will,  as  a  rule, 
be  no  primary  cerebral  symptoms.  All  cases  demand  opera- 
tion, whether  they  display  cerebral  symptoms  or  not.  The 
chief  object  is  to  limit  sepsis,  remove  foreign  matter,  and 
provide  drainage,  but  extensive  explorations  into  brain  sub- 
stance must  not  be  done. 

Treatment. — In  all  other  classes  of  head  injury  Trotter 
repeatedly  insists  that  the  treatment  must  he  based  upon 
evidence  of  cerebral  injury;  that  is  to  say.,  the  surgeon  jnust 
regulate  his  operative  interference  solely  upon  the  evidence 
collected  by  systematic  neurological  examination  of  the  pa- 
tient. This  principle  does  not  apply  to  the  type  7iow  under 
consideration.     All  of  these  cases  demand  primary  surgical 


FOREIGN  WAR  LITERATURE.  115 

interference^  whether  they  dhplay  cerebral  sympto'ni/i  or 
not.  The  chief  ohject  of  such  treatment  is  the  limitation  of 
sepsis,  the  removal  of  fragments  of  hone  and  other  foreign 
substances  from  the  brain,  and  occasionally  the  prorision  for 
the  escape  of  collections  of  blood  and  disorganized  tissue. 

It  will  be  se€n  also  that  this  treatment  differs  from  that 
which  has  been  found  most  satisfactory  in  gunshot  fractures 
of  the  extremities.  In  such  cases  it  is  generally  acknowl- 
edged that  any  primary  operative  interference  wiith  the  frac- 
tured bone  is  to  be  avoided,  for  it  is  found  that  the  soft  parts 
may  be  seriously  infected  without  the  Ijone  being  also  in- 
volved. An  operation  on  the  fracture,  therefore,  conveys 
infective  material  to  the  previously  unaffected  bone.  In 
gunshot  injuries  of  the  skull  the  fracture  is  in  close  relation 
to  the  surface  wound  and  can  scarcely  fail  to  participate  in 
its  infections.  There  are.  moreover,  two  especial  reasons 
^^ily  such  cases  should  not  be  treated  b}^  purely  expectant 
methods:  First,  the  great  danger  that  spreading  infections 
of  the  brain  and  meninges  may  start  from  the  collection  of 
pulped  brain,  blood,  fragments  of  bone,  and  foreign  sub- 
stances which  is  apt  to  be  retained  in  the  wound ;  and,  sec- 
ondly, that  grave  interference  with  the  function  of  the  brain 
is  likeh^  to  result  from  the  retention  of  such  materials,  even 
if  healing  should  occur  without  suppuration. 

The  surgeon  must  keep  in  mind  the  importance  of  doing 
no  further  dainage  and  of  aroiding  any  risk  of  actually 
spreaxli/ng  sepsis.  The  primciry  removed  of  foreign  sub- 
stances deeply  embedded  in  the  brain  is  not  cdicays  an  indis- 
pensable necessity,  and  the  satisfaction  of  recovering  a  bullst 
shoidd  not  be  allowed  to  tempt  the  snrgeon  into  enterprising 
explorations  at  this  early  period. 

If  the  patient  is  seen  soon  after  the  injury  the  following- 
treatment  should  be  carried  out  as  far  as  the  circumstances 
allow.  An  anesthetic  should  be  given  and  the  scalp  about  the 
wound  should  be  shaved  and  cleansed.  It  may  be  necessary  to 
enlarge  the  skin  wound  to  permit  of  the  proper  inspection  of 
the  damaged  parts.  Depressed  and  loose  fragments  of  bone 
and  foreign  substances  such  as  are  accessible  to  gentle  and 
cautious  examination  should  be  removed.  Any  badly  dam- 
aged and  befouled  skin  should  be  cut  away  and  the  wound 
left  widely  open.  The  whole  of  these  manipulations  may 
with  advantage  be  carried  out  under  continuous  irrigation 
with  sublimate  lotion  (1-1000  to  1-2000). 

The  Avounds  of  entry  and  exit  due  to  the  transit  of  a  bullet 
through  the  skull  must  be  regarded  as  coming  within  the 
class  of  localized  injuries  here  considered  and  be  dealt  with 
accordingly.  Many  of  such  cases,  however,  will  show  evi- 
dence of  gross  intracranial  hemorrhage,  and  of  course  ur- 
gently demand  .surgical  treatment  under  that  category  as 
well.' 

Should  the  patient  not  come  under  treatment  until  some 
days  after  the  injury,  infective  conditions  may  already  have 
developed.     Nevertheless  the  same  treatment  as  that  already 


116  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

described  must  be  carried  out.  wliether  cerebral  symptoms 
have  appeared  or  not. 

The  wound  in  all  cases  should  be  treated  by  large  wet 
dressings  frequently  changed.  Whether  or  not  these  are 
impregnated  with  antiseptic  substances  seems  to  matter  much 
less  than  whether  or  not  they  are  kept  moist  and  reneAved 
often.  The  familiar  boracic  fomentation,  which  when  care- 
fully prepared  and  properly  applied  may  be  regarded  as  a 
typical  wet  aseptic  dressing,  is  perhaps  as  satisfactory  as  any. 


It  will  be  noted  in  the  above  abstract  that  Trotter  admits  in  his 
treatment  few  of  the  qualifying  limitations  incident  to  war.  In 
this  particular,  as  we  shall  see  later,  he  differs  from  most  of  his  Eng- 
lish colleagues. 

The  papers  by  Sargent  and  Holmes  illustrate  admirably  this  differ- 
ence in  personal  viewpoint,  and  in  addition  furnish  opinions  on 
practically  every  moot  point  concerned  in  the  interpretation  and 
treatment  of  head  injuries. 

Sargeant,  P.,  and  Holmes,  G.:  Report  of  Late  Results  of  Gunshot 
Wounds  of  the  Head.    ■/.  lloii..  Army  M .  Tor/^.s-,  1916.  xxvii,  Sei">t. 

Late  results  iu  head  wounds  are  always  of  interest  since 
they  are  largely  dependent  upon  the  mode  of  early  treat- 
ment. 

The  authors  had  ample  opportunity  to  study  their  cases, 
many  of  wdiom  were  injured  18  months  and  two  years  ago. 
They  had  authority  from  Sir  Alfred  Keough,  D.  G.,  to  visit 
all  the  hospitals  in  London  and  vicinity.  This  gave  them  an 
opportunity^  to  study  the  condition  of  1,239  patients.  After 
excluding  scalp  wounds  without  any  bony  or  cerebral  injury, 
and  where  the  nature  of  the  injury  was  uncertain,  as  well  as 
others  in  which  the  information  was  too  recent  for  <)  study 
of  late  cases,  the  accurate  data  is  given  concerning  610 
patients,  75  per  cent  of  whom  were  studied  three  months 
after  the  infliction  of  injury.  The  cases  included  in  the  list 
are  more  severe  than  the  average  of  cases  diagnosed  as  gun- 
shot wounds  of  the  head. 

The  mortality  after  evacuating  to  England  was  as  follows: 
Of  the  1,239  cases  studied  in  eight  hospitals,  the  mortality 
was  3.7  per  cent.  Some  of  the  cases  were  severe  and  died 
within  two  weeks  after  admission.  But  five  cases  succumbed 
after  three  months,  the  other  deaths  occurred  before  the  end 
of  this  time.  The  immediate  cause  of  death  could  not  be  as- 
certained in  a  considerable  number  of  the  cases.  In  22  post- 
mortem examinations,  it  was  found  that  nearly  all  had  died 
of  the  spread  of  septic  infection.  In  one  remarkable  case, 
the  bullet  had  passed  through  the  right  frontal  region,  the 
base  of  the  brain,  then  ricocheted  oft'  the  Pitres  j)ortion  of 
the  temporal  bone,  thence  through  the  third  ventricle  and  the 
posterior  third  of  the  corpus  callosum  and  into  the  left  oc- 
cipital lobe.  The  patient  died  at  the  end  of  three  and  one- 
half  months  very  suddenly,  Avhen  all  cerebral  symptoms  had 


FOREIGN    WAR    LITERATURE.  117 

disappeared,  as  a  result  of  rupture  of  an  aneurism  of  the  pos- 
terior communicating"  artery. 

Eleven  patients  died  after  operation :  Two  after  excision 
of  cerebral  hernia",  two  after  jH-imary  operations,  one  after 
an  attempt  to  remove  a  lodged  shrapnel  ball  deeply  em- 
bedded in  brain  tissue,  and  in  the  remainder  death  followed 
operations  to  relieve  hernise  or  to  evacnate  cerebral  abscess. 
In  10  out  of  17  other  cases  studied  at  post-mortem,  menin- 
gitis, and  cerebral  abscess  caused  death  of  the  7  others. 

No  death  occurred  in  the  cases  studied  when  the  dura 
remained  uninjured  I)V  the  missile  or  at  f)peration. 

The  improvement  of  physical  disabilities  ^^  ith  the  lapse 
of  time  is  spoken  of  in  a  most  encouraging  wa^^  The 
amount  of  disability  is,  of  course,  dependent  upon  the  se- 
verity of  the  injury  and  the  location  of  the  lesion.  The 
authors  hold  to  the  view  that  most  of  the  paralyses,  sensory 
and  visual  disturbances,  etc.,  noted  in  the  earlier  stages  are 
due  not  so  much  to  the  result  of  destruction  of  brain  tissue 
as  to  concussion,  edema,  and  vascular  disturbances  that  ex- 
tend beyond  the  primary  injury,  and  here  they  might  have 
added  as  a  result  of  the  vibratory  force  incident  to  high 
velocity  on  the  part  of  the  projectile.  The  temporary  na- 
ture of  paralyses  in  the  corcl  is  due  to  the  same  cause,  and 
here  we  have  noted  that  the  symptoms  subside  early,  just  as 
they  are  known  to  pass  away  with  time  in  many  cases  of 
brain  injuiy. 

Disa})pearance  of  symptoms  directly  due  to  destruction  of 
brain  tissue  are  more  ]Dersistent.  and  yet  the  amount  of  im- 
provement in  some  of  the  cases  was  surprising.  A  small 
proportion  of  cases  with  perforating  and  penetrating  wounds 
of  the  skull  afflicted  with  paralysis,  sensory  disturbances, 
hemianopia,  etc.,  have  already  been  returned  to  active  serv- 
ice and  others  have  returned  to  wage-earnings  in  vocations  in 
civil  life. 

Amelioration  has  been  especially  noticeable  in  many  of 
the  cases  of  various  forms  of  paralysis  due  to  injury  of  the 
superior  longitudinal  sinus.  As  to  neurological  complica- 
tions, the  authors  note  that  but  few  cases  of  insanity  or  epi- 
lepsy have  developed  among  the  convalescent  patients  or 
those  wdio  have  been  restored  to  duty.  Dullness,  loss  of 
memory,  irritability,  and  childishness  are  oftentimes  pres- 
ent in  the  earlier  stages,  but  these  tend  to  disappear  or  di- 
minish with  time.  Onlj^  eight  cases  of  insanity  were  noted  in 
the  first  12  months. 

"  As  evidence  of  the  apparent  rarity  of  insanity  after  head 
injuries,  it  is  pointed  out  that  only  one  case  Avas  received  at 
the  London  County  Council  Area,  where  all  cases  of  insanity 
in  invalided  soldiers  naturally  go,  from  at  least  one-seventh 
of  the  population  of  the  itnited  Kingdom.  Maj.  F.  W. 
Mott,  of  the  London  County  Council  Asylums,  states  that  he 
is  very  skeptical  of  a  large  number  of  cases  of  insanity  aris- 
ing from  traumatic  causes.  He  believes  that  head  injuries 
apart  from  syphilis,  alcohol,  and  hereditary  neuropathic 
taint  seldom  cause  mental  affection. 


118  WAR   SURGEEY   OF    THE    FEEVOUS   SYSTEM. 

LikeAvise  epilepsy  of  the  Jacksonian  type  has  been  surpris- 
ingly rare,  and,  seen  in  later  stages,  it  has  been  less  common 
than  was  feared  from  the  generally  accepted  opinions  on 
the  subject.  It  has  occurred  in  6  per  cent  of  the  610  cases. 
In  8  one  convulsion  had  taken  place;  in  12  only  a  few;  5 
men  were  reported  to  have  had  5  or  6  convulsions;  while 
in  11  the  convulsions  were  frequent. 

The  admAmstration  of  hroinidc  in  all  serious  cranial  inju- 
ries until  the  wound  is  healed  and  for  some  months  after- 
ward is  considered  advisable.  Headache  is  mentioned 
among  other  neurological  complications;  and  again  a  feel- 
nig  of  weight,  pressure,  or  throbbing  in  the  head,  aggravated 
by  noise,  fatigue,  exertion,  or  emotion,  attacks  of  dizziness 
and  nervous  or  deficient  control  over  emotions  or  feelings 
aie  noted.  Many  of  the  patients  exhibit  a  considerable 
change  in  temperament.  They  become  depressed,  moody, 
irritable,  or  emotional,  and  unable  to  concentrate  their  atten- 
tion on  any  physical  or  intellectual  work.  These  symptoms 
nre  neurasthenic  in  ty])e.  They  are  independent  of  the  site 
or  severity  of  the  original  wound  and  they  are  often  as 
severe  when  a  minor  injury  like  a  scalp  wound  has  been 
received  as  in  the  case  of  a  serious  compound  fracture  of  tlie 
skull,  and  they  seem  to  develop  just  as  often  after  an  opera- 
tion as  not. 

In  reviewing  these  remote  etfects  of  head  wounds  it  is  well 
to  remember  that  a  great  deal  of  our  knowledge  of  this  class 
of  cases  has  been  handed  down  to  us  by  medicomilitary 
Avriters  who  had  viewed  the  subject  from  a  military  stand- 
IDoint  after  years  of  experience. 

LongTnore.  from  his  extensive  experience,  states  that  fen- 
cases  of  head  injury  from  g-.inshot,  be  they  contusion  or  frac- 
ture, fail  to  give  symptoms  of  cerebral  disturbance.  The 
fact  that  paralytic  symptoms  are  more  severe  at  first  and 
tend  to  disappear  wholly  or  partly  has  been  a  matter  of 
common  observation  by  military  surgeons.  Dizziness,  irri- 
tability, headache,  and  other  of  the  neurological  symptoms 
are  prone  to  recur  while  on  dutj^  in  hot  climates,  so  that 
soldiers  frequently  have  to  be  discharged  from  the  service 
on  this  account.  Although  many  of  the  cases  of  head 
wounds  have  been  restored  to  the  colors,  it  is  doubtful  if 
the}^  could  continue  on  duty  in  tropical  countries. 

Out  of  010  head  cases  to  reach  England,  120  had  cerebral 
hernia.  The  progress  and  outcome  in  cases  with  this  unfor- 
tunate complication  are  dealt  with  according  to  the  different 
types  of  wounds.  Of  the  610  cases  96  had  missiles  lodged 
in  the  brain,  and  of  26  from  whom  the  missile  had  been  i-e- 
moved  by  operation  6  developed  hernia  cerebri,  witli  2 
deaths.  Out  of  69  cases  with  missiles  in  situ  14  developed 
hernia  cerebri,  with  2  deaths.  Of  the  16  who  survived  Avith 
hernia,  the  hernia  had  shrunken  and  the  wound  had  healed 
Avhen  last  heard  from,  and  in  2  the  herniie  were  smaller  and 
the  wounds  were  healing  rapidly  three  and  four  montlis,  re- 
spectively, after  the  date  of  injury. 


FOREIGN    WAR   LITERATURE.  119 

In  68  cases  of  "  tlirough-and-tlu-oiigli  *■  shots  14  developed 
cerebral  hernia;  4  out  of  the  14  died,  and  in  8  of  the  others 
the  wounds  were  completely  healed  >vhen  last  heard  from. 
Out  of  310  cases  of  penetrating  wounds  without  rerainecl 
missile,  86  reached  England  with  cei'ebral  hernia.  There 
were  19  deaths  among  these,  and  in  49  the  wounds  healed 
completely.    Of  the  86,  62  had  been  operated  upon  abroad. 

Mention  is  made  of  69  cases  of  lodged  missile  in  the  brain 
at  some  distance  from  the  point  of  entry.  A  few  of  the  mis- 
siles were  riile  bullets  and  a  few  were  shrapnel  balls,  but  the 
great  majority  were  fragments  of  shell,  frequently  multiple 
and  not  accessible.  Four  of  the  <)9  cases  died,  and  of  the  sur- 
viving 65  cases,  12  had  been  wounded  less  than  3  months  pre- 
viously, 25  between  3  and  6  months,  21  between  6  and  12 
months,  and  7  for  over  1  year.  In  76  per  cent  of  the  cases 
the  wounds  had  completely  healed ;  in  30  per  cent  complete 
recovery  had  occurred  and  no  symptoms  of  cerebral  lesion 
were  present ;  in  40  per  cent  the  neurological  symptoms  had 
improved  to  a  remarkable  extent:  in  10.5  per  cent  hemiple- 
gia, hemianopia.  neurasthenia,  etc.,  still  persisted,  but  the 
condition  is  attributable  to  the  damage  done  by  the  missile 
rather  than  to  its  presence. 

The  conclid^ions  are  as  follows: 

The  later  results  of  head  wounds  as  shoAvn  by  their  report 
is  more  satisfactory  than  had  been  generally  expected.  It  is 
observed  that  the  proportion  of  patients  who  die  after  trans- 
ference to  England  (fixed  hospitals)  is  small,  but  the  same  is 
true  of  all  war  wounds  of  the  head. 

Later  complications,  such  as  cerebral  abscess,  are  rela- 
tively rare,  and  later  complications  or  sequelae,  as  insanity 
and  epilepsy,  are  as  yet  much  less  common  than  has  been 
foretold.  The  diminution  of  cerebral  hernia  is  doubtless 
due  to  antiseptic  treatment  of  the  wounds  in  the  beginning, 
and  as  for  the  later  sequelfe  more  time  than  one  year  should 
be  allowed  to  pass  before  a  definite  statement  can  be  made 
as  to  their  possible  occurrence. 

The  authors  reeo'rnnhend  only  such  surgical  infer ve nf ion 
at  the  front  as  may  he  called  for  to  establish  necessary  drain- 
age and  the  healing  of  the  wownd.  Every  precaution  should 
be  taken  to  prevent  the  development  of  hernia  cerebri.  The 
advice  to  avoid  the  attempt  at  remoN  al  of  lodged  foreign 
bodies  in  the  brain  is  sound,  since  it  may  involve  spread  of 
infection  or  further  destruction  of  brain  tissue,  but  to  state 
that  many  patients  with  foreign  bodies  lodged  deeply  in  the 
brain  are  scarcely  more  liable  to  serious  complications  than 
men  in  whom  the  brain  had  been  merely  exposed  and  lacer- 
ated sounds  prematui'e  in  view  of  the  short  time  which  has 
elapsed  since  the  occurrence  of  injury  anci  the  lack  of  oppor- 
tunity to  study  the  cases  under  the  varying  and  trying  con- 
ditions of  vocations  generally. 


120  WAR    SURGEEY    OF    THE    NERVOUS    SYSTEM. 

Sargent,  P.,  and  Holmes  G.:  The  Treatment  of  Penetrating  Wounds 
of  the  Skull.    Brit.  Jour,  of  Sun/.,  Vol.  II,  1916,  p.  474. 

Skull  wounds  are  classified  as  follows: 

A. — Tangential  wounds  in  Avhich  the  missile,  usually  a 
rifle  bullet,  has  passed  superficially  to  the  bone,  leaving  its 
mark  externally  in  the  form  of  a  gutter  of  the  scalp,  or 
of  two  wounds  with  a  bridge  of  skin  between  them.  Tan- 
gential wounds  of  this  kind  may  cause  no  fracture  at  all,  or 
merely  a  slight  depression  of  the  inner  table  without  lacera- 
tion of  the  dura  mater.  In  the  more  severe  cases,  however, 
the  bone  is  comminuted,  and  the  dura  lacerated,  whilst  at 
the  same  time  fragments  of  bone  are  driven  into  the  brain 
substance,  though  rarely  to  any  great  depth. 

B. — Penetrating  wounds  in  which  the  missile  has  passed 
immediately  beneath  the  bone,  along  the  chord  of  a  small 
arc.  In  these  cases  laceration  of  the  dura  and  brain  is 
naturall}^  inevitable;  and  although  the  bony  fragments  are 
for  the  most  part  driven  outwards,  yet  some  may  at  the 
same  time  have  penetrated  more  or  less  deeply.  These 
wounds  often  result  in  the  destruction  of  an  area  of  cerebral 
cortex  which  is  relatively  large  in  extent  as  compared  with 
its  depth,  presenting  a  condition  for  which  some  operation 
of  covering-in  the  exposed  brain,  combined  with  free  drain- 
age, may  be  adopted. 

C. — Direct  localized  blows  by  fragments  of  shell  or  shrap- 
nel bullets  which  have  themselves  failed  to  penetrate  the 
skull,  but  which  nevertheless  often  drive  fragments  of  bone 
deeply  into  the  brain,  so  deeply  in  fact  that  even  if  the 
ventricle  is  not  actually  opened,  its  proximity  to  the  septic 
track  is  such  as  to  render  its  infection  highly  probable.  In 
many  of  the  fatal  cases  post-mortem  examination  has  shown 
that  this  condition  existed.  In  removing  fragments  of  bone 
from  anj^  depth,  the  position  of  the  lateral  ventricle  should 
always  be  kept  clearl^^  in  mind,  lest  it  should  be  accidentally 
opened  in  the  course  of  the  operation. 

D. — Penetrating  wounds  in  which  a  missile  has  entered^ 
and  remained  lodged  within  the  brain  substance. 

E. — Cases  in  which  a  rifle  bullet  has  passed  across  the 
cranial  cavity,  the  wounds  of  entry  and  exit  being  on  op- 
posite sides  of  the  head,  or  so  far  apart  that  the  intervening 
bone  is  undamaged,  or  at  most  only  fissured.  Here  it  is  onlj^ 
at  the  entrance  wound  that  fragments  of  bone  are  in-clriven ; 
and  as  the  bony  opening  is  usually  only  a  small  puncture, 
the  fragments  are  often  mere  splinters. 

Loss  of  consciousness  of  varying  depth  and  duration,  gen- 
eral muscular  flaccidity,  and  disturbance  of  cardiac,  respira- 
tory, and  vasomotor  action,  are  amongst  the  most  striking 
of  these  general  symptoms;  but  their  exact  pathological  or 
mechanical  basis  is  still  imperfect!}^  understood.  Whatever 
it  may  be,  it  results  in  a  suspension  or  disturbance  of  func- 
tion from  which  (except  in  patients  who  die  outright  or 
Avithin  a  few  hours)  recover}^  can  take  place  spontaneously. 

Associated  with  these  disturbances  we  find  a  group  of 
symptoms  due  to  the  abnormal  increase  of  the  intracranial 


F()KEI(}N    WAR    I.ITEEATURE.  121 

pressure.  This  is  the  stage  of  cerebral  (iKlema.  and  its  effects 
may  be  aggra\'ated  by  the  presence  of  effused  blood,  which 
either  mingles  freely  with  the  excessive  cerebrospinal  fluid 
or  may  be  more  or  less  localized  or  circumscribed.  The  ex- 
perience of  a  large  number  of  cases  has  shown  that  such 
hemori'hages  are  ver}^  rarely  large  enough  either  to  threaten 
life  or  to  demand  operatiA^e  interference.  The  possibility 
of  a  hemorrhage  sufficiently  large  to  demand,  and  suffi- 
ciently localized  and  accessible  to  be  amenable  to,  direct 
operative  treatment,  is  therefore  so  removed  that  explora- 
tion on  this  account  is  rarely  desirable,  more  especially  in 
view  of  the  danger  of  infection  which  would  be  incurred 
from  the  presence  of  a  septic  scalp  Avound.  The  stage  of 
cerebral  oedema  may  last  for  several  days,  and  in  the'  absence 
of  a  spreading  infection,  subsides  spontaneously. 

In  addition  to  the  symptoms  of  general  cerebral  disturb- 
ance of  function,  those  due  to  the  local  damage  must  be 
taken  into  account.  Evidence  of  the  local  injury  is  afforded 
by  disturbance  of  motor,  sensory,  reflex,  mental,  and  visual 
functions,  according  to  the  region  involved.  Such  impair- 
ment of  function  depends  partly  upon  actual  destruction  of 
cerebral  tissue,  and  partly  upon  contusion^  localized  cedema. 
local  "  concussion'''' ;  from  tTie  effects  of  the  former  no  im- 
provement can  he  obtained  hy  operation,  ivhile  that  part  of 
the  symptom- syndrome  due  to  th£  latter  causes  is  capable 
of  more  or  less  com..plete  recovery  without  surgical  interfer- 
ence. As  it  is  not  possible  at  first  to  say  how  great  a  share 
the  one  oi'  the  other  contributes  to  the  clinical  picture,  no 
accurate  prognosis  can  be  made.  It  is  certain,  however,  that 
operative  interference  can  not  directly  benefit  either  condi- 
tion, and  recovery  of  function  is  sometimes  lorongly  ascribed 
to  the  operation  which  precedes  it.  On  the  other  hand, 
any  progressive  loss  of  function  usually  points  to  the  neces- 
sity for  affording  free  drainage  of  the  damaged  brain,  as  it 
may  be  due  to  a  secondary  inflammatory  process  which  may 
lead  to  an  extension  of  the  area  permanently  damaged. 

In  many  respects  all  these  penetrating  injuries  are  alike; 
they  present  similar  difficulties,  are  attended  by  the  same 
danger,  and  offer  similar  problems.  It  is  easy  to  regard 
them  merely  as  compound  fractures  complicated  by  injury 
to  underlying  structures,  and  to  assume  that  they  require 
exactly  the  same  treatment  as  compound  fractures  in  gen- 
eral. This  view  holds  good  so  far  as  the  essential  point  of 
eliminating  infection  is  concerned,  but  the  problem  is  by 
no  means  so  simple  as  at  first  sight  it  appears  to  be.  How 
to  secure  efficient  drainage  of  the  damaged  brain  is  one  of 
the  chief  difficulties,  and  this  arises  principally  from  two 
facts;  first,  that  the  brain  swells  so  easily  in  response  both 
to  traumatism  and  to  inflammation ;  second,  that  the  amount 
of  extra  room  which  the  cranial  cavity  is  capable  of  afford- 
ing is  so  small  in  relation  to  this  swelling. 

As  regards  the  operative  details,  these  cases  may  be  looked 
upon   as  falling  into  one  of  two  groups,  according  to  the 


122  WAR    SURGERY   OF    THE    NERVOUS   SYSTEM. 

depth  to  which  bone  fragments  have  been  in-driven  and  to 
which  brain  tissue  has  been  damaged.  In  the  first  and  larger 
group  are  found  those  cases  in  which  the  scalp  wound,  bone 
defect,  and  dural  opening  are  comparatively  small,  but  in 
which  the  underlying  brain  has  been  penetrated  and  lac- 
erated to  such  a  depth  that,  after  the  removal  of  bone  frag- 
ments, the  tract  requires  drainage  b}''  a  tube.  In  the  second 
are  included  those  in  which  the  dural  laceration  and  the 
cerebral  injury  are  greater  in  extent  than  in  the  former 
group,  but  are  comparative!}^  superficial — where,  in  fact, 
after  cleaning  and  removal  of  bone  fragments  no  tract  into 
the  brain  exists  into  which  a  tube  could  be  inserted. 

The  tirrve  at  which  operation  should  he  undertaken  is  a. 
viatter  of  very  great  importance  and  one  upon  which  opin- 
ions vary.  In  considering  the  question,  it  is  necessary  to 
have  a  clear  conception  as  to  Avhat  ends  are  to  be  attained  by 
the  operation  and  in  what  manner  it  is  expected  to  benefit 
the  patient.  Two  main  considerations  nmst  be  taken  into 
account,  namely,  the  cerebral  injury  as  such,  and  the  pres- 
ence of  an  infected  wound.  As  regards  the  neurological 
symptoms^  operation  is  rarely  if  ever  called  for  at  an  early 
stage^  and  seldom  at  a  later  one.  From  the  point  of  view  of 
the  wound  itself,  it  would  naturally  seem  at  first  sight  that 
immediate  operation  would  offer  the  best  prospect  of  re- 
covery and  prompt  healing;  and  this  would  doubtless  be 
true  but  for  two  special  circumstances:  FiTstly.,  the  ease  with 
xohich  the  suh arachnoid  space  can  he  infected;  secondly,  the 
tendency  which  exists  toward  the  formation  of  a  hernia 
cerehri.  Experience  has  shown  that  delay  tninimizes  hoth 
these  dangers^  as  may  he  appreciated  from  the  following 
considerations: 

Firstly.^  as  regards  meningitis:  The  chief  safeguard 
against  a  generalized  meningeal  infection  is  the  formation  of 
adhesions  between  the  edges  of  the  dural  wound  and  the 
contiguous  pia-arachnoid,  by  which  means  the  subarachnoid 
space  is  shut  off;  this  process  is  assisted  by  the  pressure  of 
thie  swollen  brain  against  the  dural  opening. 

Secondly.,  as  regards  hernia  cerehri:  When  the  intracranial 
pressure  is  raised,  and  there  exists  a  defect  in  skull  and  dura 
mater,  brain  matter  tends  to  be  extruded.  In  the  early  or 
concussion  stage  the  brain  is  swollen  from  traumatic  edema, 
and  consequently  the  intracranial  tension  is  raised  consider- 
ably above  the  normal ;  any  fresh  manipulation  is  followed 
by  a  further  rise  in  pressure:  with  any  meningeal  infection 
the  pressure  is  still  further  increased.  The  formation  of  a 
hernia  cerebri  is  not  only  dangerous  to  life,  but  also  to  func- 
tion— the  function  not  only  of  the  brain  actually  protruded, 
but  also  of  that  pait  which  lies  in  the  neighborhood  of  its 
base.  This  danger,  then,  provides  a  second  reason  against 
immediate  operation.  Naturally  there  is  some  risk  in  alloAv- 
ing  bone  fragments,  which  may  be  infected,  to  remain  buried 
inthe  brain,  because  an  infective  encephalitis  may  spread 
from  such  a  focus  and  may  reach  the  ventricle.  The  re- 
spective dangers,  those  of  meningitis  and  of  hernia  formation 


FOBETOX    WAP.    [JTERATTTRE.  .  123 

nttendiint  upon  the  earlier  operation  and  that  of  ventricular 
infection  which  besets  delay,  have  to  be  balanced  against  one 
another:  but  the  ex])erience  of  a  large  number  of  cases  has 
gone  to  show  that  the  dangers  of  the  eai'lier  operation  aj-e  the 
greater. 

The  question  of  the  renwoal  of  metallic  fragments  is  dif- 
hciilt  to  decide,  inasmuch  as  their  ultimate  fate  and  their 
possible  effects  upon  the  surroimcling  brain  are  at  present 
uncertain.  8uch  evidence  as  has  accumulated  up  to  the 
present  time  seems  to  shoiv  that  foreign  bodies  are  hest  left 
alone  unless  they  are  so  superfidal  as  to  he  easily  removed 
along  with  the  hone  fragments ;  or  umless  at  a  later  period 
they  cause  symptoms  directly  referable  to  their  presence. 

Two  considerations  malce  one  hesitate  before  removing 
even  easily  accessible  pieces  of  metal.  Firstly,  although  sev- 
eral patients  haA^e  made  good  recoveries  after  removal,  sev- 
eral others  have  died,  undoubtedl}'  as  the  direct  result  of  the 
operation.  Secondly,  many  patients  in  whom  removal  Avas 
not  attempted  have  gone  home  with  good  prospects  of  re- 
covery, and  several  of  these  of  whom  we  have  since  heard 
are  still,  after  many  months,  doing  well  and  with  the  wounds 
completely  healed. 

If  it  is  decided  not  to  remove  the  foreign  body,  the  wound 
of  entrance  must  nevertheless  be  dealt  with  as  efficiently,  and 
upon  the  same  lines,  as  if  no  foreign  body  were  present. 

The  authors  say  that  the  following  operation  has  fur- 
nished them  their  best  results  : 

The  whole  scalp  is  cleanly  shaved,  thoroughly  rubbed  over 
V7ith  gauze  dipped  in  alcohol,  and  painted  with  2  per  cent 
iodine  spirit;  the  wound  shares  the  same  treatment.  When 
the  position  of  the  operative  field  is  convenient,  a  tourniquet 
of  rubber  drainage  tubing  is  tied  tightly  round  the  head  be- 
low the  inion,  and  immediately  above  the  auricles  and  eye- 
brows; to  prevent  the  band  slipping  down  over  the  brows, 
and  possibly  damaging  the  eyeballs,  it  is  secured  to  the  scalp 
by  a  couple  of  sharp-]:»ointed  skin  clips.  The  operation  is 
conducted  from  start  to  finish  under  a  rapid  stream  of  hot 
normal  sal/me  solutAon.  This  is  an  important  point,  as  much 
softened  brain  and  infective  material  is  washed  away,  and 
at  the  same  time  the  operative  field  is  kept  unobscured  by 
blood. 

The  next  step  is  to  excise  the  edges  of  the  scalp  wound  just 
above  the  limits  of  visible  bruising  and  laceration  of  the 
skin ;  any  torn  and  bruised  aponeurosis  or  muscle  can  be  cut 
aAvay  from  beneath  after  turning  down  the  flap.  A  large 
flap  is  now  cut.  the  shape  and  size  of  which  necessarily  vary 
v/ith  the  position  and  size  of  the  wound  which  occupies  its 
center.  It  should  be  large  enough  to  expose  an  area  of  bone 
vv-ell  l^eyond  the  limits  of  the  bony  opening  which  is  to  be 
made ;  it  is  hetter  to  make  too  large  than  too  small  a  flap. 

The  opening  in  the  bone  is  now  enlarged  so  as  to  expose 
the  dura  mater  for  at  least  half  an  inch  all  around  the  dural 
wound.  Usually  it  is  best  to  make  a  trephine  hold  along- 
side the  bony  opening,  and  to  work  from  this;  if  one  at- 


124  WAR   SUEGEEY   OF    THE    NERVOUS   SYSTEM, 

tempts  to  enlarge  the  existing  opening  by  inserting  a  forceps 
blade  beneath  its  edge,  there  is  considerable  risk  of  produc- 
ing further  damage  and  of  disturbing  the  adhesions  between 
dura  and  pia-arachnoid  at  the  edges  of  the  clural  wound. 
Any  loose  fragments  of  bone  are  next  picked  out,  and  then 
the  finger  is  very  gently  inserted  through  the  dural  wound 
into  the  softened  disintegrated  brain.  Directly  a  bony  frag- 
ment is  felt  it  is  picked  out  with  dissecting  forceps.  This 
procedure  is  persisted  in  until  all  the  fragments  have  been 
Tvithdrawn.  It  is  of  the  utinost  importance  not  to  enlarge 
the  dural  opening^  vihich  is  almost  inoariahly  of  sufficient 
size  to  permit  of  the  necessary  maiiipidations.  At  this  stage 
it  almost  ahvays  happens  that,  with  the  escape  of  softened 
brain  and  the  removal  of  the  bony  fragments,  the  general 
intracranial  tension  is  less  than  at  the  beginning;  the  dura 
pulsates  more  freely,  and  further  escape  of  particles  of  brain 
and  bloodclot  takes  place.  This  cleansing  is  assisted  by 
directing  the  stream  of  hot  saline  upon  the  opening,  a  pro- 
ceeding Avhich  at  the  same  time  checks  and  arrests  any  bleed- 
ing that  may  be  present. 

The  track  having  thus  been  cleansed  as  thoroughly  and  at 
the  same  time  as  gently  as  possible  now  requires  drainage. 
The  tube  which  we  have  found,  after  several  experiments,  to 
answer  the  purpose  best  is  a  cylinder  of  perforated  metal 
(zinc,  aluminum,  or  copper)  If  inches  long  and  three- 
eighths  inch  in  diameter.  This  tube  is  very  carefull}^  in- 
serted into  the  track,  and  the  flap  is  replaced  and  sutured,  a 
small  drain  of  rolled  rubber  sheeting  being  inserted  between 
two  stitches  at  each  inferior  angle.  By  the  time  that  the  flap 
suture  is  completed  it  is  usually  found  that  a  certain  amount 
of  disintegrated  brain  has  already  been  squeezed  into  the 
tube  throu^gh  the  lateral  holes.  This  material  is  removed  by 
means  of  a  small  curette,  still  under  the  saline  stream.  The 
lumen  is  now  dried  out  with  gauze  strips  and  filled  with 
sterilized  glycerin;  finally,  a  packing  of  gauze  soaked  in 
glycerin  is  placed  around  the  tube  and  a  large  dressing  of 
gauze  and  wool  is  applied.  Glycerin  has  proved  to  be  the 
best  application ;  it  is  hypertonic  and  consequently  appears 
to  act  in  a  manner  similar  to  that  of  a  hypertonic  salt  solu- 
tion ;  it  has  an  inhibitory  action  upon  the  growth  of  pyogenic 
cocci  and  it  seems  to  emulsify  and  to-  facilitate  the  escape 
of  the  disintegrated  brain  substance.  If  the  intracranial 
pressure  is  so  high  that  the  tube  tends  to  be  extruded  a  little 
cerebrospinal  fluid  is  withdrawn  by  lumbar  puncture,  and 
this  process  can  be  repeated  from  day  to  day,  or  as  often  as 
the  degree  of  intracranial  tension  requires  it.  At  the  sub- 
sequent daily  dressing  the  contents  of  the  lube  are  removed 
by  curetting  and  syringing;  the  interior  is  then  dried  out 
and  again  filled  with  glycerin.  The  tube  is  allowed  to  re- 
main in  for  about  a  week,  but  at  each  dressing  it  must  be 
gently  rotated  lest  it  become  fixed  by  granulations  or  brain 
matter  projecting  through  any  of  the  holes  in  its  wall.  It  is 
not  extruded  unless  the  intracranial  pressure  is  unduly 
raised,  and  thus  any  tendency  to  extrusion  is  to  be  regarded 
as  an  indication  for  lumbar  puncture. 


FOBRinX    WAR    LFTERATURE.  125 

Removal  of  shell  fragments  and  bullets. — In  a  cei'tain  num- 
ber of  cases  we  ha\i'  considered  it  advisable  to  remove 
these  forei<i:n  bodies,  especially  when  they  lay  in  compara- 
tively snperficial  and  accessible  positions.  It  is,  of  course, 
necessary  to  recognize  the  fact  that  such  operations  entail  a 
certain  amount  of  additional  damage  to  the  brain,  as  well 
as  the  risk  of  spreading  infection.  It  Is  therefore  essential 
that  the  utmost  (jentleness  should  he  used  to  avoid  these 
accidents  as  far  as  possible.  We  have  found  that  in  the 
case  of  magnetic  metal — nameh',  fragments  of  shell  and 
German  bullets,  which  together  constitute  by  far  the  largest 
number  of  such  foreign  bodies — the  use  of  a  giant  magnet 
has  enabled  us  to  effect  the  removal  with  a  smaller  amount 
of  manipulation  and  damage  than  is  possible  when  scoops 
and  forceps  have  to  be  employed. 

When  the  brain  has  been  traumatized  superficially  and 
it  is  not  necessary  to  use  a  drain,  the  brain  surface  is  covered 
over  by  plastic  flaps  fashioned  from  the  peri  cranium  lining 
the  skin  flap. 

Lumbar  puncture. — Our  e.rpertence  has  shown  that  lumbar 
puncture  is  one  of  the  most  valuable  aids  lohich  we  possess 
in  the  tt^eatmsnt  of  gunshot  u^ounds  of  the  head. 

Firstly,  it  may  be  made  use  of  to  diminish  the  intracranial 
pressure  in  the  stage  of  traumatic  edema  when  there  is  any 
tendency  to  the  formation  of  a  cerebral  hernia,  and  whilst 
waiting  for  the  sealing  off  of  the  subarachnoid  space,  which, 
as  has  been  already  explained,  renders  operation  more  safe. 
If  employed  during  this  stage,  it  must  be  done  with  great 
caution,  as  certain  definite  dangers  attend  the  removal  of 
too  large  a  quantity  of  cerebrospinal  fluid. 

In  the  second  place,  lumbar  puncture  is  made  use  of  for 
controlling  any  tendency  to  hernia  formation  after  opera- 
tion. If  the  pressure  rises  so  that  the  tube  tends  to  be  ex- 
truded, a  lumbar  puncture  should  be  done;  the  tube,  in 
fact,  affords  a  valuable  indication  as  to  the  degree  of  intra- 
cranial pressure,  and  therefore  as  to  the  advisability  of 
performing  lumbar  puncture. 


Whitaker  draws  attention  to  the  tvco  tremendously  important  fac- 
tors of  rapid  operative  technique  and  very  free  decompression.  He 
is  strongly  inclined  to  agree  with  the  previous  authors  in  his  ad- 
vocacy of  delaying  operation. 

R.  Whittaker:  Gunshot  Wounds  of  the  Cranium,  With  Special  Ref- 
erence to  Those  of  the  Brain.  Brit.  Jour,  of  Snrfi..  Vol.  II, 
1916,  p.  710. 

One  of  the  first  things  Whittaker  learned  in  connection 
with  these  cases  was  that  the  length  of  time  taken  over  the 
operations  was  of  paramount  importance.  Most  of  the 
patients  Avere  desi:)erately  ill  on  arrival  and  prolonged 
manipidations  of  any  sort,  no  matter  how  desirable  in  theory, 
were     in     ])ractice    foredoomed     to    a     fatal    termination. 


126  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

Throughout  these  operations  the  dominant  note  must  be 
speed — speed  and  free  decompression.  The  hrain  itself  is 
able  to  deed  with  small  foreign  bodies  left  in  its  substance., 
provided  always  that  it  be  given  room  through  inhich  to 
do  so. 

It  has  l)een  pointed  out  that  possibly  tliese  statements, 
through  misinterpretation,  might  be  regarded  as  dangerous. 
In  theory  it  is  essential  to  remove  every  atom  of  foreign 
matter  in  the  brain,  and  evei-y  portion  of  the  suri-ounding 
brain  substance  Avhich  has  been  in  contact  with  and  become 
infected  by  these  fragments  if  the  patient  is  to  have  his  best 
chance  of  complete  recovery.  Nevertheless,  from  purely 
practical  considerations,  the  method  of  treatment  described 
above  is  best.  The  following  conditions  are  necessary  for 
the  complete  and  safe  removal  of  all  foreigTi  bodies :  Per- 
fect X-ray  pictures;  a  correct  interpretation  of  them;  a 
knov>' ledge  of  the  nature  and  extent  of  the  infection ;  such  a 
condition  of  the  patient  as  will  permit  of  the  delay  required 
by  these  observations ;  and  a  perfect  equipment  and  environ- 
ment. It  is  raie  for  even  the  majority  of  these  conditions 
to  be  obtained;  and  in  the  present  series,  although  we  had 
an  excellent  equipment  and  environment,  yet  the  worst  cases 
came  in  in  groups  of  several  at  a  time,  together  with  other 
serious  cases  which  required  attention;  X-ray  pictures  were 
seldom  available  within  the  first  few  hours  of  admission; 
and  many  of  our  cases  i3resented  signs  of  such  urgent  gravity 
that  nothing  justified  delay  in  operation. 

From  a  practical  point  of  view  it  is  better  to  act  as  sug- 
gested ;  to  get  the  patient  safely  off  the  operation  table  and 
through  a  convalescence  which  is  stormy  and  anxious — 
watching,  it  may  be,  the  extrusion  of  several  pieces  of  bone 
from  his  cerebral  hernia,  and  finall3%  to  wish  well  as  he 
starts  for  home — rather  than  to  do  an  operation  which  the 
pathologist,  noting  that  no  bone,  metal,  or  hair  has  been 
found  by  him  in  the  brain  at  the  autopsy  can  certify  was 
complete. 

After  excision  of  the  septic  wound  or  wounds,  suitable 
incisions  are  made  and  scalp  flaps  turned  down  to  expose  the 
area  of  skull  to  be  dealt  wdth  on  a  scale  which  allows  for  the 
fact  that  in  almost  every  case  more  damage  is  found  and 
more  has  to  be  done  than  was  anticipated. 

From  the  moment  the  operation  is  started  the  whole  wound 
area  is  kept  under  continuous  irrigation  with  1-40  carbolic 
(temperature  110°   F.). 

Bleeding  vessels  in  the  brain  or  dura  and  the  great  sinuses 
when  wounded  are  dealt  with  by  muscle  grafting.  The 
control  of  hemorrhage  from  a  big  sinus,  when  done  hy 
gauze  packing,  is  a  never-ending  source  of  anxiety  and  an- 
noyance. A  piece  of  muscle  or  fascia  taken  from  the  wound, 
held  by  an  assij-tant  over  the  bleeding  vessel,  with  the  inter- 
vention of  a  smooth  rubber  glove  or  a  dam  for  a  very  short 
time,  while  the  operatic  n  is  continued,  will  control  any  hem- 
ori'haffe  from  the  brain  or  its  eoverinffs. 


FOREIGN    WAR    LITERATURE.  127 

Make  an  adequate  opening  in  the  skull,  after  which  ol>- 
\  ious  foreign  bodies,  etc.,  are  lifted  or  washed  out.  Any 
blood  clot  (and  thei-e  is  usuall.y  a  surprising  amount  of 
this)  is  scraped  oi'  washed  away,  imperforated  rubber 
sheet  or  dam  is  put  over  the  exposed  dura  mater  and  brain, 
and  a  big  perforated  rubber  sheet  over  the  wound  area. 
The  original  operation  flaps  are  turned  down  over  this,  and 
the  wound  is  dressed  with  1-20  carbolic  on  cyanide  gauze. 
Half  a  grain  of  morphine  is  then  given,  and  the  patient 
returned  to  bed.  As  much  more  morphine  as  may  be  neces- 
sary to  keej)  the  man  quiet  for  4-8  hours  is  given  as  occasion 
arises. 

The  only  other  drugs  employed  are  (1)  urotropine  in  10- 
grain  doses,  given  every  six  hours  from  the  first  in  every 
case;  (2)  aspirin  and  trional  together,  10  grains  each,  as 
frequently  as  may  be  necessary  to  control  the  heartache 
which  is  often  present  in  the  earlier  stages.  These  drugs 
are  remarkably  efficacious  in  their  action. 

The  effects  of  lumbar  puncture  are  very  transitory,  last- 
ing a  few  hours  at  the  most.  Its  performance  can  not  fail 
to  mean  an  added  strain  to  a  case  that  has  alread}^  as 
much  as  it  can  bear.  It  is  better  to  trust  to  free  decom- 
pression for  the  relief  of  intracranial  pressure.  The  cases 
in  Avhich  the  lumbar  puncture  is  likely  to  be  of  any  use  are 
comparatively  few,  and  consist  of  those  with  meningitis, 
and  not  those  Avith  increased  intracranial  pressure  due  to 
other  causes. 

A.  The  following  conditio7hs  without  doubt  demand  im- 
mediate operation:  (1)  Active  septic  processes  in  a  badly 
drained  wound:  (2)  evidence  of  cerebral  irritation,  as  fits, 
restlessness,  or  delirium;  (3)  evidence  of  cerebral  com- 
pression, notably  severe  headache;  (4)  coma  and  slow  pulse. 

B.  Cases  In  which  operat/ion  is  demanded  hy  the  con- 
ditions^ hut  should  if  possible  he  deferred. — This  group  con- 
sists essentially  of  those  with  active  and  acute  sepsis  of  the 
scalp  associated  with  evidences  of  cerebral  compression  or 
irritation.  In  these  cases,  before  opening  the  skull,  it  is 
necessary  first  to  clean  and  drain  the  superficial  tissues,  a 
result  which  can  usually  be  accomplished  within  24  hours, 
by  free  incisions  and  boracic  fomentations  changed  hourly, 
with  the  application  of  hydrogen  peroxide  on  each  occasion. 

C.  Cases  requiring  an  operation  which  inay  he  postponed 
according  to  convenience. — Clean  cases,  in  which  the  X  raj'^s 
demonstrate  depressed  fragments  of  bone;  and  those  with 
foreign  bodies  of  moderate  size,  which  can  be  localized  defi- 
nitely and  are  in  positions  which  can  be  reached  without 
further  injury  to  the  brain. 

D.  Cases  in  which  no  operation  is  required. — These  are  as 
folloAvs:  (1)  Those  with  no  evidence  of  sepsis,  bone  dis- 
placement, or  foreign  body:  (2)  those  with  no  evidence  of 
sepsis,  but  with  a  foreign  body  not  causing  progressive 
symptoms;  (3)  cases  already  submitted  to  a  primary  opera- 
tion, in  which  both  free  drainage  and  efficient  decompres- 
sion have  been  provided. 


128  WAR    SURGEBY    OF    THE    NERVOUS    SYSTEM. 

E.  Cases  about  which  there  must  always  he  some  dou-ht 
as  to  operation. —  (1)  Those  patients  whose  general  and  local 
conditions  are  apparently  hopeless;  (2)  cases  already  op- 
erated upon,  in  which  the  wound  is  healed  but  the  general 
condition  remains  unsatisf actor^y ;  (3)  cases  with  healed 
wounds  and  no  local  evidence  of  sepsis,  but  with  a  foreign 
body,  in  a  position  which  can  only  be  reached  with  diffi- 
culty, and  with  symptoms  of  grave  cerebral  injury  but  not 
of  cerebral  compression. 

On  the  period  elapsing  after  injury  before  the  operation 
is  performed. — The  common  idea  is  that  the  time  which  has 
elapsed  between  the  infliction  of  the  wound,  and  the  pati- 
ent's arrival  in  hospital  is  a  dominant  factor  in  the  prog- 
nosis. But  this  view  is  certainly  not  borne  out  by  the  facts 
here  presented.  Statistical  tables  show  a  mortality  of  over 
50  per  cent  in  the  cases  which  had  been  operated  on  before 
arrival,  and  a  mortality  of  under  10  per  cent  in  those  where 
primary  operation  was  held  over  until  their  arrival  at  this 
hospital.  This  was  certainly  not  due  to  the  selection  of 
the  worst  cases  for  early  operation  on  board  ship.  In  fact, 
the  reverse  was  the  case,  and  in  almost  all  those  which  had 
been  operated  upon  before  arrival,  the  nature  of  the  injury 
had  been  a  small  and  simple  gutter  fracture,  Avhilst  the  bad 
perforating  wounds  with  sever  cerebral  symptoms  had  been 
left  alone. 


Roberts,  Gray,  and  Horsely  take  the  stand  that  delay  is  fatal  to  a 
degree  that  warrants  early  (and  according  to  Gray)  complete  op- 
erative interferance.  Sir  Victor  Horsley's  work  is  particularly  in- 
teresting in  that  it  furnishes  newer  experimental  data  on  the  hydro- 
static and  hydrodynamic  effects  of  high  velocity  bullets  on  the  skull 
and  brain. 

Horsley,  V.:   Gunshot  Wounds  of  the   Head.     Laiifct.   Loud..   I!*!."), 
clxxxvviii,  359. 

The  author  has  employed  modeling  clay  in  carrying  out  a 
series  of  experiments  upon  the  effects  produced  by  high- 
velocity  bullets.  The  modeling  cla}'  resembles  the  tissues 
somewhat,  in  that  it  contains  a  considerable  percentage  of 
water  in  its  interstices. 

The  experiments  shoAved  that  the  so-called  explosive  ef- 
fect of  a  high-velocit}^  bullet  is  directly  proportional  (1) 
to  the  sectional  area  of  the  bullet,  (2)  to  the  velocity,  (3)  to 
the  amount  of  water  present  in  the  substance  through  which 
the  bullet  passes,  and  (4)  that  the  forces  of  disruption  are  at 
an  angle  to  the  axis  of  the  flight  of  the  bullet. 

Further  experiments  were  undertaken  to  show  (1)  where 
in  the  course  of  the  bullet  the  most  mischief  is  done,  and  (2) 
by  what  force.  The  clay  showed  that  the  maximal  disturb- 
ance is  produced  as  soon  as  the  bullet  at  its  highest  velocit}^ 
is  surrounded  by  the  largest  mass  of  wet  tissue.    This  would 


FOBEIGN   WAR  LITERATURE.  129 

explain  the  larger  aperture  of  exit  as  compared  with  the 
aperture  of  entrance. 

In  regard  to  the  forces  producing  the  injury,  these  relate 
to  the  two  movements  of  the  bullet:  (1)  Its  progression 
forward;  (2)  its  spin  around  a  central  axis  given  to  it  by 
the  rifling.  The  more  important  movement  from  the  patho- 
logical standpoint  is  the  rotary  spin.  As  regards  the  influ- 
ence of  the  shape  of  the  bullet,  the  author  believes  it  de- 
pends entirely  upon  the  transverse  area  of  the  bullet. 

Experiments  were  performed  to  determine  the  frequency 
of  the  turning  over  of  the  bullets.  These  experiments  indi- 
cate that  bullets  turn  not  infrequently,  but  turn  over  only 
once. 

From  the  clinical  standpoint  there  are  several  conditions 
to  be  considered.  Concussion  is  common  and  may  be  fatal 
without  penetration  of  the  skull.  Death  is  probably  due  to 
a  sudden  increase  in  the  intracranial  tension,  so  as  to  inter- 
fere with  functional  activities  of  the  vital  centers. 

Rise  of  intracranial  pressure  is  often  due  to  intracranial 
hemorrhage,  and  immediate  operation  is  the  only  hope  for 
the  patient. 

Sepsis  is  a  common  sequel  of  head  injuries  and  is  fre- 
quently due  to  foreign  substances  being  carried  deep  into  the 
cranial  cavity.  Rigid  antiseptic  treatment  is  advocated  to 
prevent  the  occurrence  of  sepsis.  Hernia  cerebri  may  occur 
either  from  aseptic  or  septic  wounds. 

Functional  disturbances  of  the  brain  may  involve  either 
the  sensory  or  motor  areas,  and  complete  restoration  of 
function  in  these  cases  is  questionable. 


Roberts,  J.  E.  H.:  The  Treatment  of  Gunshot  Wounds  of  the  Head 
with  Special  Reference  to  Apparently  Minor  Injuries.  Brit. 
M.  J.,  1915,  ii,  498. 

According  to  Capt.  Roberts  there  is  a  large  number  of 
gunshot  wounds  of  the  scalp  to  be  found  in  the  base  hos- 
pitals. We  might  add  that  this  is  true  of  modern  wars 
because  the  head  is  exposed  to  fire  more  than  the  remainder 
of  the  body  as  a  result  of  fighting  under  cover.  We  may 
also  add  that  this  is  specially  true  of  the  trench  fighting 
which  is  now  taking  place  on  the  western  front.  Head  cases 
generally  form  a  larger  ratio  than  they  did  in  the  days  when 
much  of  the  fighting  was  done  in  the  open.  At  the  front 
the  surgeon  sees  all  the  head  cases.  The  severe  cases  nearly 
all  succumb  in  the  first  24  hours,  and  the  proportion  of  cases 
transferred  to  the  base  hospitals  is  made  up  of  lighter  cases, 
a  fairly  large  number  of  which  come  under  the  class  of  ap- 
parently minor  injuries  referred  to. 

In  the  examination  a  skiagram  is  valuable  in  indicating 

the  presence  and   location   of  metallic  foreign  bodies.     It 

should  be  taken  at  right  angles  to  the  wound.     The  findings 

are  not  always  reliable  in  indicating  fracture.     Fracture  of 

13764—17 9 


130  WAE   SURGERY   OF    THE    NERVOUS   SYSTEM. 

the  inner  table  with  depression  may  be  present  without  show- 
ing on  the  phite,  and  again  the  plate  may  apparently  show 
a  depressed  fracture  of  the  inner  table  when  no  such  lesion 
is  present.  The  wound  should  not  be  probed  lest  superficial 
infection  be  carried  deeper.  In  septic  wounds  and  oeclema- 
tous  scalp,  unless  the  indications  are  urgent,  apply  hyper- 
tonic saline  treatment  for  one  or  two  clays  before  operating. 
Give  urotropine,  20  grains,  three  times  per  day  in  all  head 
cases ;  shave  the  scalp  completely  and  paint  with  iodine. 

The  operative  technique  consists  in  the  removal  of  all  in- 
fected tissues  by  steadying  the  scalp  with  the  fingers  and 
making  two  incisions  surrounding  the  wound  which  shall 
go  down  to  and  include  the  pericranium.  The  tissue  thus 
isolated  is  entirely  stripped  off  the  bone  and  removed.  The 
instruments  are  then  rejected.  The  incision  just  made  is  the 
first  step  and  should  not  be  deferred  to  a  later  stage  in  the 
operation.  The  wound  should  under  no  condition  be  en- 
larged through  its  septic  edges,  and  never  until  the  comple- 
tion of  the  preliminary  excision,  otherwise  the  chance  for 
primary  union  is  improbable.  The  bone  is  next  carefully 
examined,  the  periosteum  being  further  stripped  up  if  neces- 
sary. In  the  absence  of  bone  injury  the  wound  is  sutured 
without  drainage.  If  fracture  is  present,  enlarge  the  wound 
if  more  room  is  necessary,  a  half  inch  trephine  crown  is 
raised,  all  loose  fragments  and  any  possibly  infected  bone 
are  removed,  using  the  craniectomy  forceps  if  necessary.  If 
the  dura  is  uninjured  the  wound  is  closed  without  drainage, 
and  mastic  wound  varnish  and  gauze  applied.  A  firm  com- 
press of  gauze  is  put  in  place  for  24  hours.  When  the  brain 
is  lacerated,  explore  gently  with  the  index  finger,  remove  any 
fragments  of  bone  or  metal  when  readily  accessible,  place  a 
drain  into  the  brain  and  suture  the  wound  as  before. 

Of  the  118  cases  closed  by  primary  suture  without  drain- 
age 114  healed  by  first  intention,  3  showed  slight  superficial 
sepsis,  and  1  broke  down  altogether. 

The  size  of  the  wound  at  times  offers  difficulty  in  making 
proper  approximation.  This  is  overcome  most  generally  by 
freeing  the  scalp  for  some  distance  around  the  wound  by 
lifting  the  cranial  aponeurosis  with  an  elevator. 

It  is  inadvisable  to  open  the  dura  in  the  presence  of  a 
septic  wound.  In  30  cases  in  the  Rouen  area  in  which  ex- 
cision of  the  infected  vround  was  first  resorted  to,  the  dura 
was  opened  without  a  death.  In  3  cases  in  which  the  dura 
was  opened  without  excising  the  area  of  infected  tissue, 
cerebal  abscess  and  death  occurred. 

The  methods  insisted  upon  are  as  follows : 

(1)  Careful  preliminary  examination, 

(2)  Early  operation  on  every  scalp  wound  however  slight. 

(3)  Complete  excision  of  all  infected  tissues  at  the  com- 
mencement of  the  operation. 

(4)  Eemoval  of  all  accessible  foreign  bodies  from  the 
brain. 

(5)  Primary  suture  of  wounds. 


FOREIGN   WAB   LTTEEATURE.  131 

Gray,  H.  M.  W.:  Observations  on  Gunshot   Wounds  of  the  Head. 

Brit.  ^f.  ./.,  1916,  i,  201. 

The  principles  in  the  treatment  of  these  wounds  as  de- 
duced by  Gray  are  as  follows:  (1)  Infected  gunshot  wounds 
of  the  skull  and  brain  require  more  careful  consideration 
and  prompt  attention  than  similar  wounds  of  an}'  other 
part.  (2)  Sepsis  can  best  be  combated  and  prevented  by 
early  and  complete  operations.  (3)  Permanent  disability 
can  be  prevented  in  most  cases  by  the  systematic  removal  of 
foreign  material  or  displaced  bone  from  the  surface  or  sub- 
stance of  the  brain  whenever  these  are  accessible  to  legiti- 
mate surgery.  (4)  By  these  precautions  the  immediate  re- 
sults in  the  saving  of  life  and  more  rapid  restoration  of 
function,  when  possible,  are  better  than  those  obtained  by 
more  conservative  procedures. 

The  presence  of  any  foreign  hody  in  the  hrain  may  not 
cause  imniecliate  disahiUty^  but  sooner  or  later  the  brain  is 
very  apt  to  resent  the  presence  of  these  bodies,  and  untoward 
symptoms  develop.  Fragments  of  bone,  clothing,  metal, 
etc.,  should  therefore  be  removed  as  soon  as  possible  after 
the  receipt  of  the  injury.  The  presence  or  absence  of  cere- 
bral or  cerebellar  symptoms  should  not,  in  the  average  case, 
deter  the  operator  from  the  radical  treatmeni  of  these 
wounds. 

In  minor  injuries  the  lacerated  scalp  should  be  excised  and 
sutured.     Primary  union  usually  results. 

In  depressed  fractures  of  the  inner  table  contusion  of  the 
brain  is  almost  certain  to  occur.  Ths  dura  should  l)e  opened 
in  all  such  cases,  even  when  it  is  apparently  normal,  other- 
wise injuries  to  the  brain  substance  may  be  overlooked  and 
scar  tissue  form,  which  may  cause  future  trouble.  Fur- 
thermore, the  injured  brain  substance,  if  allowed  to  remain 
untouched,  may  become  infected  and  cause  abscess,  enceph- 
alitis, or  meningitis.  When  wounds  of  the  blood  sinuses  are 
present,  it  is  thought  advisable  to  remove  depressed  frag- 
ments of  bone  for  two  reasons:  (1)  Their  retention  may 
cause  obstruction  to  the  return  of  blood  from  some  part 
of  the  brain,  or  (2)  may  lead  to  septic  thrombosis. 

As  to  drainage  of  the  hrain,  as  a  general  rule  this  should 
he  avoided  whenever  possible.  The  presence  of  definite  pus, 
infected  blood  clot,  of  inacessible  definitely  infected  foreign 
bodies,  or  profuse  oozing  would  indicate  drainage.  Bacte- 
riological examination  of  removed  substances  should  be 
made ;  and  if  streptococci  are  found,  the  drainage  should  be 
maintained  until  these  disappear  from  the  discharges  or 
become  very  few  in  number. 

Several  points  are  enumerated  by  the  author:  (1)  There 
may  be  multiple  injuries;  therefore  the  whole  scalp  should 
be  shaved.  (2)  The  force  causing  the  injury  usually  results 
in  local  injury:  injury  by  contre-coup  has  rarely  to  be  con- 
sidered. (3)  Fracture  of  the  inner  table  almost  always 
means  injury  to  the  brain  substance.  (4)  A  complete  oper- 
ation facilitates  repair,  gives  better  immediate  results,  and 


132  WAR   SUEGEEY   OF    THE    NERVOUS  SYSTEM. 

tends  to  prevent  troublesome  sequelae  more  surely  than  an 
incomplete  one.  (5)  Death  is  due  in  practically  all  cases  to 
the  effect  of  sepsis  on  the  damaged  brain.  (6)  The  aim  in 
all  operations  should  be  to  remove  as  much  infected  mate- 
rial and  tissue  as  is  feasible.  (7)  Foreign  bodies  act  dele- 
teriously  in  four  ways:  By  direct  effect  on  delicate  brain 
substance,  favoring  sepsis,  interfering  with  circulation,  and 
causing  scar  formation.  (8)  It  is  highly  important  to  pre- 
vent scar-tissue  formation,  whether  on  or  in  the  brain.  The 
nature  of  the  injury,  the  amount  of  sepsis,  the  presence  or 
absence  of  foreign  bodies,  and  the  treatment  employed  have 
much  to  do  with  the  amount  of  scar  formation. 

The  routine  of  treatment  is  as  follows :  On  admission  the 
patient's  scalp  is  shaved,  the  wound  thoroughly  examined, 
and  two  skiagrams  taken  at  right  angles  to  each  other,  and 
an  exhaustive  neurological  examination  made.  An  aperient 
is  given  and  urotropine  given.  If  the  brain  is  exposed, 
operation  should  be  done  at  once,  and  in  no  case  should 
operation  be  postponed  longer  than  two  days. 

The  majority  of  wounds  of  the  scalp  should  be  excised 
and  the  bone  beneath  carefully  examined.  If  no  bone  in- 
jury is  found,  the  wound  can  usually  be  sutured  and  primary 
union  almost  always  follows. 

Depressed  fracture  demands  immediate  exploration. 
Some  cases  without  injury  to  the  external  table  may  have 
fracture  of  the  internal  table,  usually  suspected  from  the 
location  of  wounds  or  the  clinical  findings.  Where  the  dura 
is  normal  in  appearance  and  the  brain  pulsates  well  it  may 
not  be  necessary  to  open  the  dura.  Whc^x  the  dura  is 
muddy  looking  and  the  brain  does  not  pulsate  it  should  be 
opened  up  by  means  of  a  crucial  incision.  The  useless 
brain  material  will  usually  exude. 

An  injurj^  to  the  dura  without  foreign  body  or  sepsis 
requires  careful  trimming  of  the  dura,  the  lost  tissue  being 
replaced  by  a  piece  of  aponeurosis  and  the  scalp  sutured. 
Where  a  foreign  body  or  sepsis  accompanies  the  injury  its 
withdrawal  is  attempted  and  drains  usually  inserted  along 
the  track. 

Injury  to  the  blood  sinuses  can  often  be  closed  by  the 
application  of  a  small  piece  of  aponeurosis.  The  opening  is 
carefully  cleansed  and  the  small  piece  of  fascia  then  quickly 
applied. 

Lumber  puncture  has  given  relief  from  persistent  head- 
ache in  many  cases,  but  ordinarily  no  more  than  20  cubic 
centimeters  should  be  withdrawn. 


The  w^ork  of  Don  serves  to  explain  away,  in  a  measure,  the  seem- 
ingly divergent  views  of  the  radicals  and  conservatives.  Don's  work 
was  done  at  a  casualty  clearing  station  (synonymous  with  the  Ameri- 
can Evacuation  Hospital),  and  although  he  defends  early  operation, 
he  is  careful  to  limit  the  operative  procedure  to  the  barely  essential 


FOREIGN    WAR   LITERATURE.  133 

steps  necessary  to  combat  sepsis  and  compression.     He  specifically 
warns  against  the  so-called  early  complete  operation. 

Don,  A.:  Treatment  of  Head  Injuries  in  a  Casualty  Clearing  Sta- 
tion.    Lancet,  Loud.,  1916,  cxc,  1034. 

The  author  notes  the  treatment  of  150  cases  of  head  in- 
juries operated  upon  since  the  war  began,  most  of  them  in 
a  casualty  clearing  station  which  Avas  located  in  France  not 
far  from  the  trench  fighting,  and  the  cases  came  under  treat- 
ment soon  after  the  receipt  of  the  injury.  Casualty  clearing 
stations  are  not  fully  eqiii])ped  for  work.  The}^  lack  X-ray 
machines — a  very  imi)ortant  essential  in  the  management  of 
head  cases.  The  results  given  by  the  author  were  obtained 
in  the  absence  of  X-ray  evidence,  and  as  good  as  they  are, 
they  would  naturally  have  been  far  better  with  more  com- 
plete equipment. 

The  experience  in  the  present  war  upholds  the  rule  of 
early  operation  in  all  head  cases.  Travel  in  motor  ambu- 
lances is  bad  for  head  cases,  especially  in  winter.  Delay 
means  extension  of  sepsis,  and  sepsis  is  responsible  for  the 
large  majority  of  deaths,  either  immediate  or  remote.  Ex- 
ternal scalp  wounds,  injuries  to  the  cranium,  dura,  brain, 
and  meninges  all  require  early  attention  to  prevent  sepsis, 
and  this  can  be  given  with  better  results,  because  earlier, 
where  the  casualty  stations  are  than  later  on  the  line  of 
communications. 

The  plan  followed  is  to  cleanse  the  scalp  of  all  dirt,  blood, 
and  hair.  The  field  of  operation  should  be  guarded  by  clean 
towels;  the  scalp  and  wound  are  next  painted  with  tincture 
of  iodine,  and  the  wound  is  then  excised  freely,  leaving  a 
clean-cut  edge  which  is  undamaged  to  the  eye.  If  there 
is  obvious  injury  to  the  skull,  trephining  should  be  promptly 
done.  A  hole  three-fourths  of  an  inch  in  diameter  is  made 
at  the  side  of  the  opening  or  fissure  and  the  dura  examined. 
The  trephine  opening  may  be  enlarged  with  a  rongeur,  and 
if  there  is  no  blood  clot,  opening  in  the  dura,  or  other  injury 
nothing  more  is  necessary.  If  the  dura  is  injured,  it  is  slit 
up  and  spicules  of  bone  or  blood  clot  are  removed.  Probing 
with  a  probe,  catheter,  or  finger  should  be  avoided  unless 
definite  evidence  of  the  presence  of  spicules  of  bone,  metal, 
or  other  foreign  body  is  detected.  It  goes  without  saying 
that  pressure  from  intracranial  blood  clot  should  be  treated 
in  the  same  way. 

The  flap  incision,  Avhich  was  extensively  used  in  the  begin- 
ning of  the  war,  and  the  removal  of  a  big  piece  of  the  skull 
by  the  de  Vilbiss  forceps  are  not  suitable  methods  to  use  at 
clearing  stations,  since  they  interfere  with  subsequent  opera- 
tions that  may  be  deemed  necessary. 

Shell  wounds  are  prone  to  be  followed  by  brain  abscess 
because  of  hair  and  dirt  carried  to  the  brain.  The  rifle-bullet 
wounds  are  less  apt  to  be  followed  by  abscess  or  other  com- 
plications.   Men  with  head  wounds  do  not  as  a  rule  return 


134  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

to  the  colors,  and  lodged  bullets  should  be  removed  at  home 
hospitals  where  brain  specialists  are  to  be  found.  It  is  dif- 
ferent in  cases  where  lodged  shell  fragments  are  suspected. 
They  are  much  more  apt  to  induce  sepsis  and  its  complica- 
tions, so  that  when  possible,  even  at  a  clearing  station,  the 
rule  is  to  remove  them. 

An  opportunit}^  to  study  the  results  of  English  surgeons 
w^ho  believe  in  huge  scalp  flaps  and  large  cranial  openings, 
and  those  of  the  French  surgeons  who  practice  the  linear 
or  angle  incision  and  small  trephine  openings,  is  interest- 
ingly commented  upon  in  favor  of  the  latter,  which  is  con- 
sidered far  more  appropriate  in  casualty  clearing  stations 
where  lack  of  adequate  equipment  obtains. 

Indications  for  operation  are :  (1)  The  presence  of  a  pene- 
trating wound  of  the  head;  (2)  fitness  of  patient  to  stand  a 
general  anesthetic;  (3)  the  presence  of  a  surgeon  with  some 
experience  in  cranial  surgery. 

The  average  operator  can  always  remove  dirt  from  tlie 
wound  by  a  clean-cut  incision;  open  the  cranium  wide 
enough  for  the  extraction  of  pieces  of  bone  pressing  on  the 
dura  or  sticking  in  the  brain,  to  favor  drainage  of  blood  or 
pent-up  brain  debris  and  to  restore  pulsation.  These  essen- 
tials involve  but  little  shock ;  they  require  a  minimum  of  time 
and  they  are  attended  with  immecliate  results.  When  so 
treated,  head  injuries  are  followed  by  primary  healing  in 
most  cases,  and  cerebral  hernia  is  the  exception. 

Though  gas  infection  is  rare  in  head  wounds,  free  drain- 
age should  be  afforded  by  plenty  of  drainage  tubes  inserted 
wdierever  drainage  is  called  for,  even  in  the  brain  opening. 
Ample  drainage  precludes  the  possibility  of  dead  tissue 
persisting  in  wounds,  and  when  devitalized  tissue  is  elimi- 
nated saprophites,  like  bacillus  aerogenes  capsulatus,  can  no 
longer  thrive. 

After  battles  only  the  mild  cases  should  be  transferred  to 
the  rear.  The  most  serious  cases  should  be  retained  for  some 
time  for  treatment  on  the  lines  mentioned,  which  will  put 
them  in  a  position  to  bear  the  ill  effects  of  transport. 


Gushing,  however,  seriously  interferes  with  the  spirit  of  com- 
promise noted  in  Don's  work.  Gushing  condemns  all  routine  treat- 
ment practiced  in  the  first-line  hospitals  and  advises  a  delay  of  even 
four  or  five  days  until  the  patient  can  be  subject  to  a  complete 
operation  done  under  adequate  auspices. 

Gushing,  H.:  Concerning  Operations  for  the  Craniocerebral  Wounds 
of  Modern  Warfare.    2IiI.  Surgeon,  1916,  xxxviii,  601. 

Wounds  of  the  head  and  extremities  form  a  large  majority 
of  the  total  injuries  in  the  present  war,  as  shown  by  recent 
statistics.     It  has  been  clearly  proved  that  specialization 


FOREIGN    WAR   LITERATURE.  135 

in  the  treatment  of  wounds  in  this  war  is  of  the  greatest 
vahie  in  returning  wounded  men  to  active  service  in  a  condi- 
tion of  comparative  health. 

The  importance  of  all  cranial  wounds,  however  slight, 
is  emphasized.  Roberts  found  that  in  a  series  of  140  sup- 
posedly minor  scalp  wounds  11.5  per  cent  had  skull  frac- 
tures with  more  or  less  severe  intracranial  complications. 

Gushing  is  strorujly  ojyposed  to  the  routine  treatment 
practiced  at  some  first-line  hospitals^  hy  enlargement  of 
the  wound  hy  a  crucial  incision^  elevation  of  the  depressed 
fragments,  etc.,  and  ga/uze  drainage.  He  cites  cases  in 
which  the  results  of  this  treatment  have  been  unsatisfac- 
tory or  worse.  He  believes  that  in  cases  of  cranial  wounds 
removal  to  the  base  hospital,  where  proper  equipment, 
carefully  planned  operations,  aided  by  the  X  ray,  can  be 
had,  is  the  wisest  course.  He  advises  a  flap  incision  away 
from  the  wound,  thorough  exploration,  closure  of  the  in- 
cision with  buried  galea  sutures,  supplemented  by  cutaneous 
ones  (to  be  removed  on  the  second  day)  to  insure  primary 
healing  with  scalp  protection  for  the  denuded  dura  or 
brain;  if  drainage  is  advisable,  rubber  tissue  drains  in  the 
distant  angles  of  the  incision  should  be  used,  gauze  never. 
Under  this  treatment  the  patient's  chances  are  better,  even 
after  a  delay  of  several  days,  than  with  an  immediate  opera- 
tion at  an  ill-equipped  first-line  hospital. 

The  different  tj^pes  of  cranial  wounds  from  projectiles 
are  described,  with  their  characteristic  sj^mptoms.  An  im- 
portant one  is  the  median  tangential  or  "  gutter "  wound, 
received  on  the  vertex,  involving  the  lateral  expansions  of 
the  longitudinal  sinus,  causing  stasis  in  the  large  cerebral 
veins.  The  symptoms  are  those  of  immediate  bilateral  spastic 
paraplegia  in  the  severer  cases — "  longitudinal  sinus  syn- 
drome." A  mild  case  observed  by  the  author  showed  weak- 
ness and  spasticity  of  both  legs.  The  milder  cases,  even  with 
depressed  fracture,  may  recover  without  operation.  In  the 
severer  cases,  with  cortical  injury,  operation  should  be 
undertaken  only  under  the  most  favorable  circumstances, 
the  operator  being  prepared  to  control  hemorrhage  from  a 
bleeding  sinus  by  implantation  of  raw  muscle  or  vulcanized 
fibrin  fibers;  ligation  to  be  avoided  if  possible.  The  same 
principles  apply  in  the  treatment  of  posterior  wounds  in- 
volving the  occipital  lobes  and  causing  central  blindness. 

In  general,  the  author  believes  that  good  results  follow 
a  primary  operation  luith  closure,  eve\n  four  or  five  days 
after  the  injury;  poor  results  with  death  from  meningitis 
follow  in  cases  treated  at  the  front  in  the  routine  loay  and 
packed  with  gauze. 


The  question  of  hernia  cerebri  and  brain  fungus  has  been  one  of 
the  most  perplexing  problems  to  be  met  in  the  treatment  of  gunshot 
wounds  of  the  head.     Smith,  Rawling,  and  Makins  furnish  excel- 


136  WAR   SURGEEY   OF    THE    NERVOUS   SYSTEM. 

lently  full  data  covering  this  special  field,  both  as  regards  pathology 
and  treatment: 

S.  Smith,  M.  B.:  Notes  on  the  Treatment  of  Hernia  Cerebri.    Brit. 
Med.  Jour.,  July  22,  1916,  p.  102. 

Smith  says  that  in  18  months'  experience,  with  about 
650  cases  of  gunshot  injuries  of  the  brain,  one  of  the  most 
perplexing  problems  was  that  of  preventing  or  treating 
cerebral  hernia.  The  significance  of  cerebral  hernia  lies  in 
the  i'acts  that  it  warns  us  of  increased  and  increasing  intra- 
cranial pressure,  and  that  unless  a  state  of  equilibrium  be 
speedily  established  the  patient  will  die  from  compression, 
causing  paralysis  of  his  vital  centers.  The  progressive  pro- 
trusion of  brain  matter  through  a  small  cranial  wound  may 
also  produce  further  or  new  functional  disturbance,  not  only 
because  the  herniated  brain  is  disintegrated  but  because  the 
fibers  in  its  neighborhood  are  displaced,  stretched,  and  often 
ruptured.  It  is  not,  for  instance,  rare  to  find  hemiplegia 
supervene  where  a  hernia  develops,  either  in  the  frontal  or 
post-parietal  region. 

A  hernia,  too,  especially  if  large,  acts  as  a  direct  menace 
by  reason  of  the  tendency  for  it  to  become  gravely  infected, 
and  for  this  infection  to  spread  to  the  underlying  brain 
substance,  leading  to  a  generalized  cerebritis,  or  to  the 
spread  of  infection  into  the  lateral  ventricle.  The  danger 
of  this  latter  event  is  all  the  greater  because  often  there  is 
a  diverticulum  of  the  ventricle  in  the  hernia. 

Serious  infection  of  the  hernia  is  most  likely  to  occur  in 
those  cases  where  it  is  strangulated,  as  so  often  happens  when 
the  bony  opening  through  which  it  protrudes  is  too  small, 
the  familiar  "  button  "  hernia,  with  its  attenuated  and  con- 
stricted pedicle,  being  thus  produced.  Such  strangulation 
of  the  protrusion  is  followed  by  softening  and  sloughing, 
and  thus  the  facility  for  deep  infection  is  increased. 

It  has  seemed  to  me  that  the  brain,  perhaps  because  nor- 
mally it  is  so  efi'ectually  covered  and  protected  by  its  bony 
envelope,  evinces  more  than  any  other  tissue  of  the  body  a 
tendency  when  exposed  to  become  ulcerated  and  sloughy, 
and  this  should  be  given  great  weight  when  the  question 
of  operative  measures  comes  to  be  considered. 

It  IS  of  importance,  apart  from  the  danger  of  opening  up 
the  highly  susceptible  subarachnoid  space,  that  the  clural 
opening  already  produced  bj'^  the  wound  should  not  be 
enlarged.  Still  more  important  is  it  not  to  incise  the  dura 
if  it  be  found  intact,  as  this  procedure  is  accompanied  by  the 
grave  risk  of  infecting  the  damaged,  but  not  septic,  brain 
underneath,  thus  leading  to  the  very  condition  of  affairs 
favorable  to  the  formation  of  a  hernia  that  we  are  doing  our 
utmost  to  prevent. 

As  a  means  of  diminishing  the  cerebral  exposure,  Smith 
found  suture  of  the  edges  of  the  scalp  wound  after  excision 
of  the  edges  of  the  original  wound  only  possible  in  a  rela- 


FOREIGN   WAR  LITERATURE.  137 

tively  small  proportion  of  our  cases,  the  wound  generally 
having-  been  far  too  extensive  and  septic  for  the  perform- 
ance of  such  a  desirable  procedure.  Moreover,  where  such  a 
method  of  closure  has  seemed  practicable,  the  tension  neces- 
sarih^  produced  would  have  made  efficient  drainage  very 
difficult,  and  there  is  an  obvious  objection  to  a  tight  suture 
lying  pressed  up  against  the  exposed  brain,  which  we  are 
trying  both  to  protect  and  to  drain. 

It  "goes  almost  without  saying  that  another  eminently 
desirable  factor  in  the  prevention  or  limitation  of  hernia 
cerebri  is  the  effective  treatment  of  the  ever-prevalent  sepsis, 
both  by  the  use  of  efficient  drainage  with  frequent  dressings 
Avhere  necessary,  and  also  by  the  use  of  antiseptic  lotions. 

It  is  i'nvportant  to  mahe  use  of  gravity  in  the  treatTnent 
of  hernia  cerebri  and  also  in  its  prevention,  and  with  this 
end  in  view  we  always,  when  possible,  sit  our  patients  up 
as  soon  as  they  are  sufficiently  recovered  from  the  effects  of 
the  operation;  this  procedure  is,  unfortunately,  impracti- 
cable in  many  cases.  In  those  cases,  however,  in  which  it 
can  be  done,  this  maneuver  has  a  remarkable  effect  in  limit- 
ing the  hernia,  and  will  even  cause  it  to  subside  altogether 
in  manj^  cases.  It  is  specially  efficacious  in  hernia?  of  the 
frontal  region  or  near  the  vertex,  where  gravity  has  full 
play  and  the  tendency  for  the  brain  is  to  fall  away  from 
the  wound.  It  is  also  important  that,  by  the  free  adminis- 
tration of  morphine,  heroin,  or  similar  drug,  the  patient 
should  be  kept  quiet  and  so  prevented  from  bruising  his  her- 
nia by  knocking  it  against  the  head  rail — a  by  no  means  rare 
occurrence.  With  this  end  in  view,  too,  it  is  well  to  keep 
the  hernia,  if  protruding  to  any  extent,  surrounded  by  a 
sufficiently  large  "  buffer  "  of  wool  to  prevent  injury. 

In  spite  of  every  care,  however,  hernia  cerebri  will  always 
be  met  with  in  a  certain  numbei  of  cases,  both  following 
operation  and  also  in  those  in  which  no  operation  has  been 
performed.  It  is  here  that  the  systematic  use  of  lumbar 
puncture  is  of  the  utmost  value. 

It  is  im/portant,  too,  that  the  fluid  l>e  tvithdrawn  slowly, 
almost  drop  l)y  drop,  as  otherwise  the  hernia,  with  the  too 
sudden  relief  of  pressure,  may  sink  hack  through  the  Jjony 
opening  into  the  hrain,  leaving  a  deep  cavity  where  hefore 
there  ivas  a  large  hernia.  This  is  dangerous,  for  adhesions 
may  he  hroken  down  and  a.  sep)tic  meningitis  lighted  up. 
The  intervals  allowed  to  elapse,  between  which  repetitions 
of  the  puncture  are  necessary,  depend  on  many  factors,  some 
of  which  will  now  be  discussed:  If  after  the  first  puncture 
the  hernia  shows  no  sign  of  decreasing,  and  compression 
symptoms  do  not  decrease,  it  has  generally  been  our  practice 
to  repeat  the  tapping  on  the  alternate  days,  until  the  pres- 
sure as  shown  by  the  manometer  readings  is  brought  down 
to  within  reasonable  limits;  in  a  few  cases  of  high  pressure 
with  rapidly  increasing  hernia  and  progressive  signs  of 
compression  we  have  repeated  the  operation  daily,  though 
this,  in  my  experience,  is  rarely  necessary,  the  tapping  on 


138  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

alternate  days  giving  equally  good  results.  If  the  fluid  is 
clear,  thus  showing  that  there  is,  in  all  probability,  no  in- 
flammatory process  at  work,  it  is  permissible  to  wait  longer 
before  repeating  than  if  it  is  turbid,  crowded  with  leu- 
cocytes, and,  maybe,  giving  growths  of  organisms  on  cul- 
ture. One  can  not  assume,  however,  that  clear  cerebro- 
spinal fluid  drawn  off  by  lumbar  puncture  necessarily  means 
absence  of  meningitis,  for  more  than  one  of  our  patients 
have  died  in  whom  lumbar  puncture  gave  clear  fluid  until 
the  last,  though  subsequent  autopsy  revealed  extensive  sup- 
purative meningitis. 


Rawling,  L.  B.:  Hernia  Cerebri.    Surcery  of  the  Head,  Oxford  Press, 
1915,  p.  106. 

There  are  two  varieties  of  hernia  cerebri,  the  aseptic  form 
and  the  septic  or  ordinary  type. 

Aseptic  hernia  cerebri. — In  consequence  of  the  explosive 
effect  of  a  bullet  on  the  normal  brain,  if  portions  of  the 
bones  of  a  skull  are  carried  away,  then  the  rise  of  intra- 
cranial pressure  will  cause  a  certain  amount  of  extrusion  of 
brain  substance.  Owing  to  hemorrhage  in  the  brain  sub- 
stance produced  by  the  explosive  effect,  such  a  hernia  tends 
to  remain  just  as  long  as  there  is  increased  intracranial 
pressure  (Horsley).  It  is  argued  that  in  a  clean  wound 
there  may  be  such  venous  engorgement  and  cerebrospinal 
edema  as  will  raise  the  general  intracranial  pressure  to 
such  an  extent  that  brain  substance,  more  or  less  normal, 
will  protrude. 

Septic  hernia  of  the  brain. — When  the  dura  mater  is 
opened  in  the  normal  individual,  there  is  not  the  slightest 
tendency  for  the  brain  to  protrude  through  the  membranous 
opening.  On  the  other  hand,  if  the  intracranial  pressure 
be  increased  by  tumor,  hemorrhage,  etc.,  the  brain  will  at 
once  protrude  through  the  opening  and  will  continue  to  do 
so  until  such  an  amount  of  brain  matter  has  been  extruded 
as  will  bring  the  intracranial  pressure  again  to  the  normal 
condition.  This  is  the  result  aimed  at  in  ordinary  decom- 
pressions, whether  temporal,  cerebellar,  or  in  other  situa- 
tions. In  such  cases,  however,  the  protruding  brain  is  cov- 
ered with  some  scalp  constituents  and  the  wound  is  clean. 
To  such  brain  bulgings  the  term  hernial  protrusion  is  best 
applied.  During  such  operations,  also,  if  the  opening  in  the 
bone  and  the  dura  be  of  considerable  size,  the  brain  will  not 
bulge  too  suddenly,  the  pia  and  arachnoid  membranes  will 
not  be  ruptured,  the  brain  pressure  is  fully  compensated, 
and  the  pia  and  arachnoid  being  whole,  there  is  but  little 
tendency  for  the  brain  to  become  adherent  to  the  scalp.  In 
some  cases,  no  doubt,  the  pia-arachnoid  ruptures  and  surface 
vessels  burst,  but  the  bulging  brain  can  still  be  covered  with 
scalp.  There  is  some  risk  of  formation  of  adhesions,  but 
the  condition  is  still  one  of  hernial  protrusion,  not  hernia 
cerebri. 


FOREIGN    WAR    LITERATURE.  139 

On  the  other  hand,  if  the  bone  be  extensively  destroyed 
(or  removed  by  operation),  if  the  dura  be  widely  lacerated 
(or  freely  opened),  and  if  the  brain  be  under  considerable 
pressure  by  reason  of  contained  fragments  of  bone,  bullet, 
etc.,  especially  when  such  foreign  bodies  are  infective,  then 
the  injured  brain- will  bulge  outwardly,  to  an  extent  propor- 
tionate to  the  increased  pressure,  and  will  appear  on  the  sur- 
face. This  is  the  condition  known  as  hernia  of  the  brain 
(cerebri  and  cerebelli),  the  brain  appearing  on  the  surface 
as  a  red,  granular  mass,  pulsating  freely,  slightlv  constricted 
at  its  base,  and  with  some  surface  suppuration.  The  appli- 
cation of  jDressure  leads  to  some  diminution  in  size,  but  any 
more  forcible  attempts  at  such  i-ecluction  in  size  results  in 
headache,  unconsciousness,  and  perhaps  in  the  development 
of  fits. 

There  is,  however,  a  third  condition  to  be  described,  fun- 
gus of  the  brain,  an  even  more  serious  condition. 

In  such  conditions  the  brain  herniates  through  a  small 
opening  in  the  dura  mater,  the  constriction  at  the  neck  of 
the  hernia  interfering  with  the  venous  return,  both  from 
the  herniated  mass  and  in  the  immediate  neighborhood  of 
the  neck  of  the  hernia.  In  consequence,  both  the  hernia 
itself  and  the  neighboring  brain  will  be  in  a  state  of  venous 
engorgement  and  cerebrospinal  oedema,  with  consequent  in- 
crease in  pressure.  The  protrusion,  therefore,  will  tend  to 
continue  to  increase  in  size  and  more  and  more  brain  matter 
Avill  become  extruded.  A  vicious  circle  is  established,  the 
fungus  increases — perhaps  to  such  an  extent  that  a  great 
mass  of  brain  substance  may  be  extruded  on  to  the  surface, 
with  terrible  organic  disturbances. 

If,  now,  there  is  added  to  this  condition  the  existence 
within  the  brain  of  fragments  of  bone  or  bullet,  all  infective, 
the  tendency  to  herniation  is  all  the  greater.  These  facts 
suffice  to  explain  the  frequency  with  which  we  see  hernia  of 
the  brain  in  this  present  war. 

Fungus  'of  the  hrain  appears  on  the  surface  as  a  moist, 
cauliflowerlike  mass,  readily  bleeding  and  freely  discharg- 
ing sero-purulet  fluid.  Pulsation  is  present,  but  not  nearly 
so  free  and  forcible  as  in  hernia  of  the  brain.  The  con- 
striction at  the  neck  of  the  mass  acts  in  damping  pulsa- 
tion much  in  the  same  way  as  constriction  at  the  neck  of  a 
hernial  sac  interferes  with  impulse  on  cougjiing.  The  ap- 
plication of  pressure  to  the  hernia  has  but  little  effect  in  the 
reduction  of  the  mass.  It  should  be  added  that  the  increase 
in  size  of- the  protrusion  is  always  due  in  part  to  the  develop- 
ment of  granulation  tissue,  the  growth  of  which  is  exceed- 
ingly free  on  the  brain  substance. 

If,  now,  a  section  could  be  taken  through  the  fungus,  deep 
into  the  underlying  cortex,  it  would  be  seen  (1)  that  the  nar- 
row neck  is  more  or  less  strangulated  by  the  edges  of  the 
dural  opening;  (2)  that  the  subjacent  brain  is  softer  than 
normal,  discolored  and  congested,  oeclematous,  and  without 
any  defined  margins,  shading  off  in  the  rest  of  the  brain; 


140  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

and  (3)  that  the  horn  of  the  ventricular  cavity  of  the  brain, 
which  is  in  closet  relation  to  the  protrusion,  is  expanded  in 
that  direction,  and,  in  the  more  serious  cases,  that  it  actually 
passes  without  the  limits  of  the  skull  so  as  to  occupy  the 
central  portion  of  the  hernia  itself,  even  bursting  at  the 
apex  of  the  protrusion,  discharging  a  copious  stream  of 
cerebrospinal  fluid. 

Fortunately,  both  in  hernia  and  fungus  of  the  brain, 
meningeal  infection  is  of  lesser  frequency  than  might  be 
imagined.  The  "  swollen  "  brain  lies  in  close  contact  with 
the  dura,  obliterating  the  subdural  space,  and  adhesions 
form  with  great  rapidity  between  the  other  membranes, 
affording  fairly  efficient  barrier  to  meningeal  spread  and 
infection. 

Symptoms. — If  the  hernia  involves  the  "  silent "  areas  of 
the  brain,  frontal  and  temporo-sphenoidal  lobes,  there  may 
be  no  special  urgent  symptoms,  provided  that  the  clegree  of 
protrusion  compensates  fully  for  the  increased  intracranial 
pressure.  In  fact,  in  many  cases,  the  patient  feels  per- 
fectly well. 

If  the  protrusion  includes  the  motor  cortex,  the  results 
are  disastrous — spastic  paralysis  of  the  contralateral  side  of 
the  body,  with  apasia  in  the  event  of  the  left  side  of  the 
brain  being  involved,  with  exaggerated  reflexes,  Babinski, 
and,  later  on,  secondary  contractures. 

If  the  occipital  cortex  protrudes,  the  patient  will  suffer 
from  hemianopia,  etc. 

In  addition,  as  a  general  rule,  hernia  of  the  brain  is  asso- 
ciated with  some  mental  symptoms — lethargy,  headache, 
cerebral  irritation,  or  actual  insanity — varying  in  degree 
according  to  the  size  of  the  hernia  and  its  physiological 
importance. 

Treatvient :  Rawling  outlines  the  following  treatment  for 
hernia  cerebri : 

Class  1. — Of  hernia  of  the  brain,  purposedl}^  produced, 
fully  compensative  and  not  increasing. 

Class  2. — Of  hernia  of  the  brain,  resulting  from  injury  or 
from  operation,  noncompensative  and  tending  to  increase. 

Class  3. — Of  fungus  of  the  brain. 

In  class  1  the  desired  result  has  been  attained,  the  protru- 
sion compensating  for  the  previous  increase  of  intracranial 
pressure.  All  that  remains  to  be  clone  is  to  keep  the  exposed 
brain  clean  and  dry,  favoring  by  rest  its  recession  and  clos- 
ing over.  It  is  to  be  hoped  that  the  protrusion  will  dimin- 
ish in  size,  perhaps  actually  receding  entirely,  as  the  degree 
of  venous  congestion  and  cerebrospinal  edema  lessens.  In 
the  event  of  the  more  f aA^orable  result,  the  skin  will  grow  in 
from  the  sides,  finally  covering  in  the  protrusion,  after 
which  some  form  of  curved  metal  cap  will  have  to  be  worn 
to  protect  the  region  from  the  effect  of  accidental  blows, 
etc.  If  the  overgrowth  of  skin  is  slow  or  imperfect,  the  sur- 
face may  be  skin  grafted  (after  Thiersch's  method).  Re- 
cession may  be  aided  by  periodic  lumbar  puncture  and,  in 
the  more  intractable  cases,  by  a  contralateral  decompression. 


FOREIGN   WAR  LITERATURE.  141 

To  keep  the  hernia  "  dry  and  clean  "  the  region  must  be 
first  cleansed  with  washings  of  hydrogen  peroxide  and  fo- 
mentations, renewed  every  two  hours.  Fomentations  of 
saline  solution  give  the  best  results.  When  clean,  fomen- 
tations arc  discarded  and  dry  dressings  applied,  together 
with  some  antiseptic  powder,  e.  g.,  boric  powder.  These 
dressings  are  renewed  daily,  the  old  dressing  being  washed 
off,  the  hernia  dried,  painted  over  with  iodine,  and  fresh 
gauze  applied.  The  brain  itself  is  insensitive  and  the  daily 
dressi'^QS  are  practically  painless. 

If  the  hernia  is  obstinate,  refusing  to  decrease  in  size,  it 
may  be  ]:>ainted  over  every  third  day  with  a  40  per  cent  solu- 
tion of  formalin,  the  tissue  necrosing  and  drying  up.  The 
destruction  of  the  protruding  mass  does  not  make  the  condi- 
tion of  the  patient  any  worse,  so  far  as  the  functions  of  the 
region  are  concerned.  These  are  already  destroyed,  and  no 
further  bad  effects  can  develop. 

1)1  class  2  the  hernia  is  increasing  in  size  after  apparent 
adequate  and  deliberate  opening  of  both  dura  and  brain. 
This  occurrence  results  by  reason  of  the  infectivity  of  the 
brain  or  because,  in  addition,  there  are  foreign  bodies  in  the 
brain,  keeping  up  the  pressure  and  increasing  the  degree  of 
infection.  Thus  a  bullet  in  the  brain,  even  though  nonin- 
fective  or  of  slow  infectivity,  produces  such  congestion  and 
oedem'T  as  demands  further  protrusion,  till  fully  compen- 
sated, though  such  desirable  results  are  not  easily  attained. 
Again,  a  more  highly  infected  bullet,  or  fragments  of  bone, 
may  result  in  diffuse  cerebritis  or  localized  abscess,  both  of 
which  conditions  produce  such  "  swelling "  of  the  brain  as 
results  in  an  increasing  protrusion.  In  such  cases  it  is  ob- 
vious that  complete  X-ray  pictures  will  be  of  the  greatest 
assistance  both  in  determining  the  cause  and  indicating  the 
line  of  treatment. 

First  of  all,  it  is  obvious  that  the  exciting  cause  must  be 
removed  if  possible,  bone  fragments  or  bullet  being  extracted 
and  an  abscess  evacuated  and  drained.  This  being  done, 
and  a  considerable  protrusion  remaining,  the  measures  avail- 
able pre  as  mentioned  in  the  previous  section.  The  hernia 
may  be  painted  with  a  40  per  cent  solution  of  formalin  or 
with  alcohol  every  third  day,  and  on  the  two  intervening 
days  with  a  2  per  cent  solution  of  iodine  in  spirit.  By  these 
mea^-s  the  i^rotrusion  mav  necrose  and  shrivel. 

The  hernia  may  be  shaved  off,  though  usually  growing 
again.  Unfortunately,  also,  the  protrusion  often  contains 
in  its  base  the  expanded  and  dilated  horn  of  the  lateral  ven- 
tricle, and  the  shaving  off  of  the  protrusion  will  uncover 
that  region  to  direct  infection,  in  addition  to  permitting  of 
the  frpe  escape  of  cerebrospinal  fluid.  Rawling  has  carried 
out  this  procedure  on  some  few  occasions,  and  has  never 
seen  any  harm  result,  whilst  in  two  or  three  instances  the 
ultimate  result  obtained  by  the  shaving  process  has  been 
quite  satisfactory.     The  mass  is  cut  away  flush  with  the  sur- 


142  WAE    SUEGERY   OF    THE    NEEVOUS   SYSTEM. 

face  of  the  skull,  bleeding  being  arrested  by  the  immediate 
application  of  dressings  and  firm  bandage.  The  wound  is 
re-dressed  daily.  The  protrusion  may  not  redevelop,  and 
healing  may  take  place.  In  one  instance  he  shaved  away  the 
hernia  three  times  before  it  quieted  down  and  scarred  over. 
The  protruding  brain  is  quite  useless  so  far  as  its  functions 
are  concerned.  There  is  no  objection  to  the  shaving  away 
of  the  hernise  from  that  point  of  view. 

As  a  last  resource,  there  is  the  question  of  conducting  a 
contralateral  decompression,  with  the  object  of  relieving 
the  intracranial  pressure  and  recession  of  the  hernia.  The 
decompression  should  be  conducted  over  the  opposite  tem- 
poro-sphenoidal  lobe,  for  if  that  lobe  does  bulge  outwardly 
there  are  no  after  ill  effects.  Thus  in  a  right-sided  hernia 
the  operation  should  be  a  left  subtemporal  decompression. 

In  any  case  the  decompression  opening  must  be  free,  both 
as  regards  dura  and  bone.  After  the  operation  more  pres- 
sure is  applied  to  the  hernia  than  previously.  The  "  win- 
dow "  allows  protrusion  in  another  place  and  assists  in  the 
recession  of  the  hernia,  after  which  it  may  scar  over  or  be 
grafted  after  Thiersch's  method. 

The  ultimate  result  in  all  these  cases  will  hinge  largely  on 
the  cortical  region  inv^olved.  If  possessing  known  function, 
that  function  will  be  permanently  impaired  or  lost.  Conse- 
quently, the  more  serious  results  are  seen  after  hernise  of  the 
Rolandic  and  occipital  regions.  With  frontal  or  temporo- 
sphenoidal  hernia?  the  patient  may  get  quite  well. 

In  class  S,  fungus  of  the  brain,  the  protrusion  is  gripped 
at  its  neck  and  continually  tends  to  increase  in  size.  Such 
being  the  case,  the  cause  must  be  tackled.  The  condition  is 
desperate  and  the  following  course  must  be  pursued — 
the  hernia  shaved  away,  the  margins  of  the  dural  opening 
defined,  and  that  membrane  freely  slit  up.  There  is,  of 
course,  the  danger  of  infecting  the  meninges,  but  so  far  as 
Rawling's  experience  goes  such  a  result  is  of  unlikely  occur- 
rence with  due  precautions.  After  shaving  the  hernia  away 
the  whole  region  is  sponged  with  iodine,  and  here  and  there 
a  director  insinuated  for  a  short  distance  beneath  the  dura 
and  the  membrane  slit  up  freely  in  several  directions.  The 
increased  opening  ought  to  relieve  the  strangulation.  The 
future  care  and  progress  of  the  case  is  indicated  in  the  pre- 
ceding section. 


Makins,  Geo.  H.:  Illustrations  of  War  Surgery.     Brit.  Jour.  ISurg., 
No.  10,  1916,  p.  263. 

Makins  cites  two  cases  of  fungus  cerebri  which  improved 
under  nonoperative  treatment.  Percy  Sargent  appends  the 
following  comment  on  this  subject: 

The  term  ''hernia  "  is  often  used  to  describe  this  condi- 
tion, but  it  is  best  kept  to  indicate  the  protrusion  of  unin- 
jured brain  through  a  large  opening  deliberately  produced 
as  a  decompressive  measure.     The  term  "  fungus "  is  con- 


FOREIGN    WAR   LITERATURE.  143 

veniently  retained  to  designate  such  protrusions  of  damaged 
semistrangulated  septic  brain  and.  granulation  tissue  as  are 
here  illustrated. 

The  escape  of  brain  matter  from  the  cranial  cavity,  which 
is  so  frequently  seen  in  the  earliest  stages,  is  due  to  the 
sudden  increase  of  pressure  caused  by  the  blow,  and  to  the 
traumatic  cerebral  oedema  which  immediately  follows.  If 
no  additional  factor  were  to  come  into  play  to  sustain  and 
increase  this  pathological  intracranial  tension,  any  initial 
protrusion  would  disappear  with  the  subsidence  of  the  trau- 
matic oedema,  and  no  fungus  cerebri  would  form.  Infection 
of  the  wound,  however,  results  in  the  onset  of  a  secondary 
inflammatory  oedema,  which  keeps  up  and  increases  the  gen- 
eral intracranial  pressure.  This  leads  to  a  further  pro- 
trusion of  the  softened  brain  through  the  dural  opening, 
which  becomes  more  and  more  tightly  plugged,  and  conse- 
quently the  drainage  of  the  damaged  sej)tic  brain  is  increas- 
ingly interfered  with.  This  interference  causes  a  still 
further  rise  in  the  intracranial  tension,  so  that  a  vicious 
circle  is  established.  Unless  relief  is  obtained  either  by 
natural  subsidence  of  the  inflammatory  process,  or  by  the 
establishment  of  free  drainage,  death  ultimatel}^  ensues  from 
meningitis. 

A  vertical  meningitis  spreading  from  the  wound  is  not 
common  unless  the  wound  has  been  inadvisedly  interfered 
with  at  a  very  early  date,  for  the  subarachnoid  space  rapidly 
becomes  sealed  off  by  adhesions  which  form  between  the 
dura  and  the  pia- arachnoid,  and  this  process  is  assisted  by 
the  fact  that  the  swollen  brain  is  pressed  firmly  against  the 
dural  opening.  Within  the  first  24  to  48  hours,  therefore, 
any  manipulation  of  the  damaged  brain  for  the  purpose  of 
removing  bone  fragments,  or  any  rapid  lowering  of  the 
intracranial  tension  by  lumbar  puncture,  is  apt  to  be  fol- 
lowed by  a  vertical  meningitis  spreading  from  the  wound. 

On  the  other  hand,  if,  after  this  danger  period  is  passed, 
free  drainage  of  the  damaged  brain  is  not  provided,  the 
infective  process  extends  deeply,  the  ventricles  become  in- 
volved, and  a  basal  meningitis  results. 

Fungus  cerebri  therefore  is  an  indication  of  the  increased 
intracranial  pressure  which  results  from  inflammatory 
oedema.  When  this  elevation  of  pressure  is  progressive,  the 
fungus  increases  in  size,  is  tense,  and  pulsates  but  feebly; 
at  the  same  time  headache  and  optic  neuritis  are  present, 
and  these,  together  with  other  pressure  symptoms,  increase 
until  death  ensues.  On  the  other  hand,  when  the  intracranial 
tension  is  relieved,  the  fungus  becomes  flaccid,  pulsates 
freely,  and  shrinks  in  size  more  or  less  rapidly. 

With  an  increasing  fungus  the  treatment  must  be  directed 
firstly  toward  controlling  the  general  intracranial  pressure, 
and  secondly  to  draining  the  infected  necrotic  brain  con- 
nected with  the  fungus ;  and  the  second  object  can  be  greatly 
assisted  by  accomplishing  the  first. 

Local  treatment. — Indriven  fragments  of  bone  should  be 
removed,  the  utmost  gentleness  being  used  in  order,  firstly, 


144  WAR   SURGERY   OF    THE    NERVOUS  SYSTEM. 

to  avoid  tearing  adhesions  and  so  opening  up  the  subarach- 
noid space ;  and  secondly,  to  avoid  spreading  infection  more 
deeply  into  the  brain  substance  and  so  toward  the  ventricle. 
If  bone  spicules  have  already  been  removed,  it  is  well  to 
explore  the  track  again,  as  occasionally  (but  rarely)  a  small 
collection  of  pus  may  be  discovered  and  drained. 

Eeduction  of  intracranial  pressure. — This  would  naturally  l)e 
best  achieved  by  removing  bone  and  opening  the  dura  freely 
around  the  fungus ;  but  such  a  course  is  forbidden  on  account 
of  the  practical  certainty  of  infecting  the  subdural  space. 
The  other  means  available  are  (1)  lumbar  puncture  and  (2) 
contralateral  decompression. 

(1)  Lumbar  puncture. — This  is  the  more  easily  applicable 
method,  with  the  additional  advantage  that  examination  of 
the  fluid  removed  gives  information  as  to  the  presence  or 
absence  of  generalized  meningitis. 

In  these  cases  the  cerebrospinal  pressure  is  generally 
found  to  be  considerably  raised,  and  a  large  quantity  of  fluid 
can  easily  be  removed.  It  is  ^vell^  however.,  not  to  allow 
Tnore  than  from  I^.  to  6  drachms  to  escape  at  one  sitting.,  lest 
the  rapid  disturbance  of  pressure  within  the  skull  should  of 
itself  lead  to  spread  of  infection.  The  operation  may,  how- 
ever, be  repeated  daily  or  every  other  day,  and  the  intra- 
cranial pressure  be  kept  under  control  by  that  means. 

{2)  Contralateral  decompression. — When  repeated  lum- 
bar puncture  fails  to  control  the  fungus  a  subtemporal  de- 
compression may  be  done  in  the  hope  that  the  complete  relief 
so  afforded  may  allow  the  necessary  drainage  of  the  septic 
brain  at  the  site  of  injury  to  take  place. 


Woodroffe  confirms  the  results  of  the  French  school  regarding 
the  efficacy  of  cartilaginous  grafts  to  close  cranial  defects.  He  is 
careful  to  specify  the  train  of  symptoms  which  call  for  grafting 
and  to  state  that  the  symptoms  are  "  often  "  cured.  In  civil  life  but 
little  has  been  accomplished  in  this  direction.  Gushing  limits  graft- 
ing to  a  small  and  almost  negligible  group  of  cases.  (Keen's  Surgery, 
VoLIII,  p.  251.) 

Warren  Woodroffe,  H.  L.:  The  Reparation  of  Cranial  Defects  by 
Means  of  Cartilaginous  Grafts.  Brit.  Jour.  Snrg.,  .July,  1917, 
Vol.  II,  p.  42. 

Cartilaginous  grafts  are  recommended  for  those  patients 
with  cranial  defects  who  show  signs  of  "  weakened  cerebral 
defenses,"  and  who  present  no  contraindication  to  opera- 
tion. 

The  symptoms  most  complained  of  are  headache,  vertigo, 
and  sudden  blurring  of  the  A^sion.  Though  these  are  com- 
mon symptoms  of  cranial  and  intracranial  trouble,  they  may 
fairly  be  laid  to  the  charge  of  the  cranial  defect  when  they 
are  brought  on  by  sudden  movement.  Inability  '^  sleep, 
except  with  the  head  raised  or  tightly  bandaged,  and  objec- 


FOREIGN   WAR  LITERATURE.  14,5 

tion  to  noise,  are  also  complained  of.  These  symptoms  can 
often  be  cured  by  a  cranioplasty. 

Technique  of  operation. — Make  a  crucial  incision  over  the 
defect.  Clean  the  circumference  of  the  edge  of  the  bone 
defect  right  down  to  the  dura,  and  freshen  the  bone  edges 
with  a  rongeur.  It  is  rarely  necessary  to  open  the  dura, 
A  swab  of  hydrogen  peroxide  is  placed  in  wound,  and  the 
flaps  turned  back  over  it. 

The  cartilages  of  the  seventh,  eighth,  and  ninth  ribs  hav- 
ing been  exposed,  shavings  are  taken  of  about  half  their 
thickness.  Care  should  be  taken  not  to  cut  through  the  en- 
tire thickness  of  a  fixed  cartilage;  but  the  whole  tip  of  a 
floating  one  ma}^  be  taken.  It  is  well  to  take  what  seems 
to  be  considerably  more  than  enough  cartilage  to  fill  the 
gap.  Each  graft,  as  cut,  is  dropped  into  warm  saline  solu- 
tion. 

The  chief  difficulty  is  to  keep  these  grafts  from  slipping. 
A  very  simple  and  rapid  method  is  that  of  Villandre.  One 
end  of  a  fine  catgut  stitch  is  passed  through  the  pericranium 
and  tied.  It  is  then  passed  through  the  pericranium  on  the 
other  side  of  the  gap  and  taken  backward  and  forward  in 
a  zigzag  manner  till  the  hole  is  covered  in  with  a  trellis.  In 
the  case  of  a  very  large  gap  it  is  wise  to  supplement  this 
network  by  a  second,  at  right  angles  to  it,  and  to  insinuate 
the  grafts  between  the  two  layers.  We  have  now  a  small 
chamber  bounded  by  the  dura,  the  edges  of  the  skull,  and 
our  trellis,  into  which  the  grafts  can  be  slipped  with  a 
forceps.  It  is  advised  to  apply  the  perichondral  surface  to 
the  dura  in  order  to  avoid  adhesions. 

Careful  wound  closure,  leaving  a  strand  of  silkworm  gut 
in  place  for  drainage. 


Although  the  subject  of  shell  shock  belongs  almost  exclusively  in 
the  realm  of  neurology  and  psychiatry,  we  include  an  abstract  of  an 
article  by  Mott,  which  represents  the  best  work  on  this  subject.  The 
original  paper  is  very  extensive  and  very  detailed  both  from  the 
clinical  and  the  laboratory  side.  The  surgeon  must  acquaint  him- 
self with  the  subject  of  shell  shock  for  the  reason  that  group  2  as 
outlined  by  Mott  is  distinctly  a  surgical  group. 

Mott,  Fred.  W.:  The  Eifects  of  High  Explosives  Upon  the  Central 
Nervous  System.    Lancet,  February  12,  1916. 

High  explosives  contained  in  huge  shells  have  played  a 
prominent  part  in  this  war,  and  apart  from  the  effects  pro- 
duced by  direct  material  injury  to  the  central  nervous  system, 
there  is  the  moral  effect  of  the  continued  anxious  tension  of 
what  may  happen,  which,  combined  with  the  terror  caused 
by  the  horrible  sights  of  death  and  destruction  around,  tends 
to  exhaust  and  eventually  even  shatter  the  strongest  nervous 
system.     To  live  in  trenches  or  underground  for  days  or 

137G4— 17 10 


146  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

weeks,  exposed  continually  to  wet,  cold,  and  often,  owing  to 
the  shelling  of  the  commimication  trenches,  to  hunger,  com- 
bined with  fearful  tension  and  apprehension,  may  so  lower 
the  vital  resistance  of  the  strongest  nervous  system  that  a 
shell  bursting  near,  and  without  causing  any  visible  injury, 
is  sufficient  to  lead  to  a  sudden  loss  of  consciousness.  So  that 
in  considering  the  effects  of  high  explosives  it  is  absolutely 
necessary  to  take  into  account  the  state  of  the  nervous  system 
of  the  individual  at  the  time  of  the  "  shock  "  caused  by  the 
explosive.  A  neuro-potentially  sound  soldier  in  this  trench 
warfare  may  from  the  stress  of  prolonged  active  service  ac- 
quire a  neurasthenic  condition,  and  it  stands  to  reason  that  a 
soldier  who  has  become  neurasthenic  from  a  head  injury  or 
from  the  acquirement  of  a  disease  prior  to  his  enlistment  will 
not  stand  the  strain  as  well  as  a  neuro-potentially  sound  man. 
Again,  if  in  a  soldier  there  is  an  inborn  timorous  or  neurotic 
disposition  or  an  inborn  germinal  or  acquired  neuropathic 
or  psychopathic  taint  causing  a  locus  minoris  resistentim  in 
the  central  nervous  system,  it  necessarily  follows  that  he  will 
be  less  able  to  withstand  the  terrifying  effects  of  shell  fire 
and  the  stress  of  trench  warfare.  Thus,  whether  a  tendency 
to  a  neurasthenic  condition  has  been  acquired  or  is  more  or 
less  inborn,  an  emotional  experience  such  as  fright  is  more 
liable  to  develop  the  symptoms  of  a  functional  neurosis  or 
psychosis. 

The  effects  of  high  explosives  upon  the  central  nervous  sys- 
tem fall  into  three  groups : 

(1)  Immediately  fatal  either  from  pieces  of  shell,  stones, 
rocks,  or  portions  of  buildings  striking  the  individual,  caus- 
ing instant  death,  or  the  person  may  be  buried  from  the  ex- 
plosion of  a  mine.  Again,  instant  death  must  have  occurred 
in  groups  of  men  from  the  effects  of  shell  fire  and  yet  no 
visible  injury  has  been  found  to  account  for  it. 

(2)  In  group  2  we  can  place  those  cases  in  which  the  de- 
tonation of  high  explosives  has  caused  wounds  and  injuries 
of  the  body,  including  the  central  nervous  system,  which  have 
not  been  immediate!}^  fatal.  The  number  of  these  cases 
which  do  not  exhibit  an}^  of  the  functional  disorders  and  dis- 
turbances characteristic  of  what  is  termed  "  shell  shock " 
without  visible  injury,  although  such  individuals  have  re- 
ceived most  serious  and  fatal  wounds  from  exploding  shells, 
leads  one  to  consider  that  in  a  large  proportion  of  cases  of 
shell  shock  without  visible  injury  there  are  other  factors  at 
work  in  the  production  of  the  nervous  symptoms  besides  the 
actual  aerial  forces  generated  by  the  explosive. 

(3)  The  third  group  includes  injuries  of  the  central  ner- 
vous system  without  visible  injury;  this  group  includes  the 
functional  neuroses  and  psychoses.  As  we  know,  one  of  the 
peculiarities  of  the  functional  neuroses  is  not  only  the  sud- 
den manner  in  which  an  emotional  shock  may  engender  a 
loss  of  function,  but  likewise  the  sudden  manner  in  which  it 
may  be  unexpectedly  restored  by  a  sudden  stimulus  of  the 
most  varied  kind,  provided  there  is  an  element  of  surprise. 
That  is,  attention  is  for  a  moment  taken  off  its  guard.     The 


FOREIGN    WAR    LITERATURE.  147 

causes  of  shock  to  the  nervous  system  by  high  explosives 
may  be  considered  under  the  headings  of  physical  trauma — 
concussion  or  "  commotio  cerebri "  by  direct  aerial  compres- 
sion or  by  the  force  of  the  aerial  compression  blowing  the  per- 
son into  the  air  or  against  the  side  of  the  trench  or  dugout ; 
or  b}'^  blowing  down  the  parapet  or  roof  on  to  him,  causing 
concussion;  or  a  sandbag  hitting  him  on  the  head  or  spine 
might  easily  cause  concussion  without  producing  any  visiljle 
injury.  Again,  he  might  be  buried  and  jjartly  asphyxiated 
or  suffer  from  deoxygenation  of  his  blood  by  CO  poisoning, 
for  these  high  explosives  generate  considerable  quantities  of 
CO,  which  is  inodorous  and  would  not  Ije  recognized.  A 
man  lying  unconscious  or  even  conscious  and  partially  buried 
and  unable  to  move  would  be  very  liable  to  be  poisoned  by 
CO  and  not  know  anything  about  it;  nor  Avould  the  rescuers, 
as  the  poisonous  effects  of  the  gas  depend  upon  the  amount 
in  the  atmosphere  and  the  length  of  time  to  which  the  indi- 
vidual is  exposed  to  it. 


The  following  abstract  calls  attention  to  the  very  necessary  co- 
operation between  ophthalmologist  and  neurological  surgeons : 

Greenwood,  Allen:  Fundus  Examinations  in  a  British  Base  Hospital. 

London  Opliiluilmoscope,  1916. 

A  four  months'  experience  during  the  heavy  fighting  of 
1916  in  making  consultation  examinations  of  the  eyes  of 
soldiers  with  head  injuries  for  one  of  the  largest  groups 
of  base  hospitals  of  the  B.  E.  F.,  an  opportunity  was 
afforded  the  writer  of  seeing  a  large  number  of  interesting 
cases.  In  the  majority  of  the  severe  head  blows  inflicted  by 
glancing  bullets,  by  shrapnel  balls  (the  so-called  furrow 
wounds) ,  or  by  an  impinging  but  not  penetrating  piece  of 
shell  casing,  resulting  in  splintering  of  the  inner  table,  or  in 
brain  destruction  without  any  splintering  whatever,  in- 
creased intracranial  pressure  will  sooner  or  later  manifest 
itself,  just  as  it  will  in  the  frankly  penetrating  and  perforat- 
ing wounds  of  the  calvarium.  One  of  the  early  signs  of  this 
increase  intracranial  pressure  will  be  an  optic  neuritis  which 
quickly  increases  to  a  typical  choking  of  the  disk.  In  these 
cases  the  neuritis  from  the  start  is  of  the  choked  disk  or 
intracranial  type,  where  the  swelling  is  confined  almost 
wholly  to  the  nerve  head  even  if  it  is  raised  several  dioptres 
above  the  normal  surrounding  retina.  This  type  of  optic 
neuritis,  which  gives  no  clue  to  the  side  of  the  brain  injured, 
may  from  its  appearances  be  differentiated  from  the  inflam- 
matory type  wdiich  is  seen  in  cases  that  develop  memingitis. 
In  the  inflammatory  type  besides  the  swollen  nerve  head 
there  is  an  extension  of  inflammatory  signs  and  oedema  out- 
ward into  the  surrounding  retina  with  hemorrhages  and  ex- 
udates giving  the  picture  seen  in  the  cerebrospinal  menin- 
gitis of  civilian  practice.  In  this  type  the  o]itic  nerve  show- 
ing the  first  signs  of  inflammation  is  that  on  the  side  where 


148  WAR   SUKGEEY   OF    THE    NEEVOUS   SYSTEM. 

the  meningitis  is  beginning.  Thus  it  is  possible  in  some  cases 
to  differentiate  between  intracranial  pressure  and  meningitis 
even  in  the  early  stages  of  these  conditions.  Where  the 
nerve  change  is  due  to  increased  intracranial  pressure  tre- 
phining over  the  injured  brain  area,  which  allows  for  the  re- 
moval of  an  extradural  or"  intradural  blood  clot  or  disor- 
ganized brain  substance  or  depressed  bone,  results  in  its 
rapid  disappearance.  A  recrudescence  of  these  nerve  condi- 
tions would  indicate  a  return  of  the  intracranial  pressure, 
demanding  further  interference.  When,  however,  the  in- 
flammatory neuritis  type  is  seen  it  usually  indicates  a  puru- 
lent meningitis  for  which  little  can  be  done.  For  the  in- 
juries of  the  back  of  the  head  besides  a  fundus  inspection 
there  should  be  a  careful  testing  of  the  visual  fields.  Such 
an  examination  will  reveal  many  cases  of  varying  types  of 
hemianopsia  from  the  complete  homonymous  hemianopsia 
to  hemianopic  scotomata  and  quadrant  defects.  Frequently 
it  will  be  found  in  the  long  furrow  wounds  across  the  oc- 
cipital region  that  the  brain  lesion  as  shown  by  the  hemian- 
opsia is  opposite  to  the  most  severe  portion  of  the  scalp 
injury.  For  a  treatise  on  the  very  careful  working  out  of 
such  fields  as  these  the  reader  is  referred  to  an  excellent  one 
by  Holmes  and  Lister.  (Proceedings  Royal  Society  Medicine, 
June,  1916.)  Some  of  the  hemianopsias  will  recover  follow- 
ing operative  interference,  while  some  will  not.  Where  the 
hemianopsia  is  not  accompanied  by  optic  nerve  changes  and 
there  are  no  other  indications  for  operation,  and  the  bone 
uninjured,  trephining  is  not  advised. 

The  writer  at  one  time  had  three  men  in  adjoining  beds 
in  his  ward  all  with  a  left  homonymous  hemianopsia,  due 
to  injury  in  the  right  occipital  region,  and  an  accompanying 
choked  where  following  a  trephining  marked  improvement 
in  the  fields  took  place.  Various  paralyses  of  ocular  nerves 
may  result  from  basal  fractures,  and  are  interesting  from 
the  standpoint  of  localization  and  diagnosis. 


The  very  latest  fully  expressed  opinions  regarding  various  phases 
of  surgery  in  war  may  be  found  in  two  papers,  published  in  June  of 
this  year  (1917)  by  G.  H.  Makins  and  Bowlby  &  Wallace.  Both  of 
these  papers  specifically  contrast  the  treatment  of  head  wounds  as 
practiced  early  in  the  war  with  the  present-day  treatment,  and  for 
that  reason  we  furnish  full  quotations.  Makins  quotes  freely  from 
the  experience  of  Col.  Percy  Sargent. 

Makins,  G.  H.:  Development  of  British  Surgery  in  Hospitals  on 
Lines  of  Communication  in  France.  Biit.  Med.  Jour.,  June  16, 
1917,  p.  800. 

A  great  change  has  taken  place  since  the  commencement 
of  the  war  both  in  the  nature  of  the  cases  and  in  their  actual 
number.  This  change  depends  on  the  one  hand  on  the  fact 
that  a  larger  number  of  these  injuries  are  retained  and  oper- 


FOREIGN   WAR   LITERATURE.  14& 

ated  upon  at  the  front  lines,  and  on  the  other  on  the  protec- 
tion afforded  to  the  head  by  the  hehnet.  The  early  treat- 
ment of  these  injuries  has  already  been  dealt  with;  it 
suffices  here  to  say  that  the  patients  which  now  arrive  have 
either  already  been  operated  upon  and  are  in  good  condi- 
tion, or  they  come  down  already  suffering  from  septic  com- 
'  plications.  The  general  lines  governing  the  treatment  of  the 
latter  class  of  cases  have  been  admirably  laid  down  in  a 
paper  in  the  British  Journal  of  Surgery  by  Sargent  and 
Holmes,  and  certain  points  in  the  technique  of  the  operative 
procedure  elaborated.  These  authors  have  also  dealt  with 
the  anatomical  and  histological  changes  associated  with  trau- 
matic injuries  and  infected  wounds  of  the  brain  and  their 
bearing  on  the  surgical  treatment  of  these  conditions.  Fur- 
ther examination  of  a  considerable  number  of  patients  some 
months  after  their  return  to  England  proved  much  more  sat- 
isfactory than  had  been  generally  expected.  It  was  found 
that  the  proportion  of  patients  who  die  after  tranference  to 
England  is  small ;  later  complications,  such  as  cerebral  ab- 
scess, are  comparatively  rare,  and  serious  sequelae,  such  as 
insanity  and  epilepsy,  are  much  less  common  than  had  been 
foretold.  In  only  15  per  cent  of  the  patients  examined,  how- 
ever, had  more  than  one  year  elapsed  from  the  date  of  the 
injury.  It  also  appeared  that  many  patients  with  foreign 
bodies  deeply  lodged  in  the  brain  recover,  and  are  scarcely 
more  liable  to  serious  complications  than  men  in  whom  the 
brain  has  been  merely  exposed  and  lacerated.  These  con- 
clusions are  obviously  only  tentative,  but  as  far  as  they  go 
appear  hopeful. 

Holmes  and  Sargent  have  also  described  a  condition  hith- 
erto rarely  seen  and  established  a  definite  symptom  syn- 
drone  for  its  recognition.  It  is  characterized  by  an  immediate 
spastic  paralysis  of  the  legs  and  frequently  associated  with 
spastic  paresis  of  the  proximal  segments  of  the  upper  limbs; 
they  have  shown  it  to  be  due  to  occlusion  of  the  superior  lon- 
gitudinal sinus  or  of  the  veins  that  enter  it  by  a  depressed 
fracture  of  the  vertex  of  the  skull.  Experience  showed  the 
results  of  surgical  interference  with  cases  of  this  class  to 
have  been  extremely  unsatisfactory.  Thus  among  39  cases 
observed  which  were  operated  upon  either  bj^  the  authors  or 
others  15  deaths  occurred,  while  among  37  cases  in  which  no 
operation  was  undertaken  only  1  died  before  transference 
to  England.  While  it  is  allowed  that  these  figures  have  no 
absolute  value,  as  naturally  only  the  most  serious  cases  were 
selected  for  operation,  and  in  seven  of  the  fatal  cases  direct 
injury  to  the  brain  was  present  in  addition,  yet  the  results 
emphasized  the  danger  of  operation.  Moreover,  the  uncom- 
plicated cases  showed  a  remarkable  tendency''  to  improve, 
probably  owing  to  the  free  venous  anastomosis  permitting  a 
reestablishment  of  the  circulation. 

An  important  contribution  to  the  localization  of  function 
in  the  brain  has  been  published  by  Lister  and  Holmes,  who 
from  a  study  of  a  large  number  of  cases  with  injury  in  the 
occipital  region  were  able  to  determine  the  relative  positions 


150  WAE    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 

in  the  cortical  visual  areas  of  the  foci  that  subserve  vision  of 
separate  portions  of  the  visual  fields.  They  bring  forward 
strong  evidence  with  regard  to  the  site  for  the  center  for 
macular  or  direct  central  vision^  of  which  very  little  had  been 
previously  known. 

The  following  conclusions  are  come  to: 

(1)  The  upper  half  of  each  retina  is  represented  in  the 
dorsal  and  the  lower  in  the  ventral  part  of  each  visual  area. 

(2)  The  center  for  macular  or  central  vision  lies  in  the 
posterior  extremities  of  the  visual  areas,  probably  on  the 
margins  and  the  lateral  surfaces  of  the  occipital  poles. 

(3)  That  portion  of  each  upper  quadrant  of  the  retina  in 
the  immediate  neighborhood  of,  and  including  the  adjacent 
part  of,  the  fovea  centralis  is  represented  in  the  upper  and 
posterior  part  of  the  visual  area  in  the  hemisphere  of  the 
same  side,  and  vice  versa. 

(4)  The  center  for  vision  subserved  by  the  periphery  of 
the  retinae  is  probably  situated  in  the  anterior  end  of  the 
visual  area,  and  the  serial  concentric  zones  of  the  retina 
from  the  macula  to  the  periphery  are  probably  represented 
in  this  order  from  behind  forward  in  the  visual  area. 

Tlohnes  and  Smith  have  recorded  observations  on  the  na- 
ture and  localization  of  motor  apraxia,  or  the  inability  to 
perform  purposeful  actions  despite  the  preservation  of 
movement  and  power  and  in  disturbance  of  the  faculty  of 
localizing  objects  in  the  external  world  by  vision. 

Probably  in  no  other  branch  of  medicine  have  so  many 
and  such  difficult  problems  arisen  as  in  the  tre^itment  of 
wounds  and  diseases  of  the  nervous  system.  Further,  in 
this  field  an  extraordinary  opportunity  has  occurred  to  ob- 
serve, analyze,  and  record  the  effects  of  local  lesions,  many 
of  which  are  rarelj^,  if  ever,  seen  in  civil  life.  When  the 
results  of  this  v/ork  are  eventually  correlated  they  must 
throw  much  light  on  the  phj^siology  and  the  symptoms  of 
disturbance  of  different  parts  of  the  brain,  spinal  cord,  and 
peripheral  nerves,  and  thus  increase  our  Iniowledge  of  the 
diagnosis  and  treatment  of  nervous  diseases.  Special  ar- 
rangements have  been  made  in  order  that  cases  under  early 
observation  in  France  should  be  sent  to  special  hospitals  in 
England,  so  that  continuous  records  will  be  maintained  of 
a  very  large  number  of  patients. 

Col.  Percy  Sargent  furnished  Makins  with  the  following- 
summary  of  his  opinions: 

The  very  large  experience  gained  of  gunshot  wounds  of 
the  head  has  led  to  a  considerable  degree  of  modification 
in  their  treatment.  Immediate  routine  operation,  often  in- 
complete and,  in  the  absence  of  full  neurological  informa- 
tion and  X-ray  examination,  sometimes  unnecessary  and 
even  misdirected,  is  no  longer  widely  practiced.  It  has  long 
since  been  made  abundantly  clear  that  early  evacuation  of 
operated  cases  is  often  followed  by  disaster.  As  it  is  impos- 
sible to  operate  upon  these  cases  and  to  retain  them  at  the 
clearing  stations  for  a  period  which  renders  transportation 
safe,  more  especially  during  times  of  great  military   ac- 


FOREIGN   WAR  LITERATURE.  ^  151 

tivity,  the  practice  now  generally  adopted  is  to  transfer 
them  without  operation  as  soon  as  possible  to  hospitals  far- 
ther down  the  line.  It  has  been  made  quite  clear  that  surgi- 
cal intervention  is  rarely  required  for  the  relief  of  cerebral 
symptoms,  whether  general  or  focal.  Its  chief  aim  is  the 
prevention  of  intradural  infection.  On  this  conception  all 
cases  of  gunshot  wounds  of  the  head  fall  into  one  of  two 
categories,  according  to  whether  the  dura  mater  has  or  has 
not  been  penetrated.  N onyenetratmg  wounds  have  a  low 
rate  of  mortality,  whether  operated  upon  or  not,  provided 
that  the  surgeon  respects  the  integrity  of  the  dura  mater. 

It  is  customary  therefore  to  do  in  these  cases  only  as  much 
as  may  seem  advisable  to  insure  speedy  healing^  such  as 
excision  of  the  edges  of  the  wound ^  removal  where  necessary 
of  bony  fragments,  and  partial  or  complete  closure  of  the 
gap  in  the  scalp  either  hy  suture  or  by  some  form  of  plastic 
operation. 

Penetrating  ivounds,  on  the  other  hand,  afford  more  room 
for  difference  of  opinion  regarding  their  treatment.  In- 
dividual cases  continue  to  present  difficulties  even  to  those 
who  have  seen  large  numbers,  but,  broadly  speaking,  there 
is  a  consensus  of  opinion  in  favor  of  the  following  line  of 
treatment:  The  wounds  having  been  cleansed  and  dressed, 
the  patient  is  transferred  as  soon  as  possible  to  a  hospital 
where  he  can  be  retained  for  at  least  a  fortnight  after  the 
operation.  A  complete  neurological  and  radiographic  ex- 
amination is  made  and  the  operative  treatment  then  directed 
according  to  the  diagnosis  thus  arri\'ed  at.  In  some  cases 
of  penetrating  uiounds  no  operation  is  indicated.,  such  as 
those  in  which  a  bullet  has  passed  completely  through  the 
head,  or  those  in  which  a  bullet  or  a  metallic  fragment  is  em- 
bedded in  the  brain  at  a  distance  from  a  small  clean  entrance 
wound  and  is  giving  rise  to  no  symptoms.  Another  class  of 
cases  for  which  operative  interference  is  usually  contra- 
indicated  is  that  in  which  the  longitudinal  sinus  has  been 
injured.  Cases  Avhere  a  track  from  the  scalp  wound  leads 
down  to  indriven  bony  fragments,  or  to  an  easily  accessible 
missile,  are  operated  upon,  briefly,  as  follows :  A  moderately 
large  flap  is  turned  down  after  resection  of  all  damaged 
tissue  around  the  scalp  wound ;  the  bony  opening  is  enlarged 
sufficiently  to  expose  thoroughly  the  opening  in  the  dura 
mater;  the  indriven  fragments  of  bone  and  metal  are  re- 
moved under  a  constant  stream  of  hot  physiological  saline 
solution;  and  the  track  is  drained  by  a  celluloid,  metal,  or 
rubber  tube  brought  out  through  the  original  wound.  In 
cases  of  more  superficial  cerebral  laceration,  where  track 
drainage  is  unnecessary,  the  principle  is  employed  of  cover- 
ing the  denuded  brain  by  some  plastic  operation  on  the 
scalp;  in  these  circumstances  drainage  tubes  emerging  from 
the  angles  of  the  scalp  flap  are  usually  employed  for  a  few 
days. 

Opinions  still  vary  regarding  the  advisability  of  operat- 
ing for  the  removed  of  bullets  or  shell  fragments.  There  is 
much  evidence  to  show  that  these  foreign  bodies  are  well 


152  WAR   SURGERY   OF    THE    NERVOUS  SYSTEM. 

retained,  and,  apart  from  the  uncommon  accident  of  late 
suppuration,  cause  no  symptoms.  It  has  been  stated  by 
more  than  one  writer  that  bullets  embedded  in  the  brain 
move  about  under  the  influence  of  gravity.  The  evidence 
for  this  view  is  wholly  unconvincing.  Eemoval  of  bullets, 
even  when  the  wounds  have  healed  and  the  risk  of  septic 
infection  thereby  is  largely  minimized,  must  be,  even  in 
skilled  hands,  attended  by  an  amount  of  damage  which 
in  most  cases  would  have  more  serious  neurological  con- 
sequences than  could  the  presence  of  an  aseptic  bullet. 

Primary  removal  of  a  deeply  seated  missile  carries  with 
it  the  additional  risk  of  septic  infection.  For  these  rea- 
sons the  usual  practice  is  to  leave  alone  such  missiles. 

The  treatment  of  indriven  fragments  of  bone  is  more 
debatable.  When  driven  into  the  brain  by  a  missile  which 
is  itself  retained,  the  bony  fragments  are  rarely,  if  ever, 
more  deeply  placed  than  the  projectile.  When  driven  in 
by  the  impact  of  a  missile  which  does  not  itself  enter  the 
cranial  cavity,  the  bony  fragments  are  rarely  found  so 
deeply  situated  but  that  they  can  be  removed  along  the 
track  with  little,  if  any,  additional  damage  being  done. 

With  regard  to  the  septicity  of  these  indriven  metallic 
and  bony  fragments,  it  has  been  found  that  a  large  propor- 
tion, when  dropped  into  culture  media  immediately  upon 
removal,  fail  to  provoke  any  bacterial  growth,  either  aero- 
bically  or  anaerobically. 

The  question  of  the  intracranial  pressure  has  been  the 
subject  of  repeated  observation.  Among  the  conclusions 
of  practical  importance  which  have  been  arrived  at  are 
the  following: 

(1)  Apart  from  the  rare  instances  of  extensive  intra- 
cranial hemorrhage,  traumatic  oedema,  whilst  playing  an 
important  part  in  symptomatology,  does  not  reach  a  suffi- 
cient degree  of  intensity  to  endanger  life. 

(2)  The  instances  of  severe  intracranial  hemorrhage 
not  rapidly  fatal  are  very  few;  and  even  amongst  these 
there  is  a  certain  number  which  surgical  intervention  is 
not  likely  to  save.  Experience  has  shown  that  an  intra- 
cranial hemorrhage  which  is  sufficiently  scA^ere  to  demand 
operative  relief,  and  which  can  be  recovered  from,  gives 
unmistakable  signs  of  its  progress.  The  operation  can  be 
deliberateh?^  planned  and  carried  out  with  the  definite  ob- 
ject in  view.  Exploratory  operations  on  the  chance  of 
discovering  a  hemorrhage  are  rarely  if  ever  called  for. 

(3)  In  case-  of  intracranial  pressure  from  secondary 
mdem,a  which  is  causing  severe  headache  and  herniation 
<of  hrain^  this  can  almost  always  he  controlled  hy  luvibar 
puncture.  Occasionally  contralateral  decompression  has 
been  done  for  these  cases  and  has  afforded  good  results. 

Such  evidence  as  is  at  present  available  from  the  later 
results  (six  months  to  two  years)  is  all  in  support  of  the 
general  policy  of  treatment  outlined  above. 


FOREIGN  WAR  LITERATURE.  153 

Bowlby,  A.,  and  Wallace,  C:  The  Development  of  British  Surgery 
at  the  Front.    Brit.  Jour.  Surg.,  June  2,  1917,  p.  719. 

At  the  beginning  of  the  war  surgeons  called  upon  to  treat 
head  injuries  applied  the  ordinary  rules  of  civil  practice 
and  operated  on  them  at  once.  Thej^  were  confirmed  in 
their  opinion  that  operation  was  right,  since,  apart  from 
the  mere  physical  defects,  many  patients  seemed  to  be  suffer- 
ing from  compression. 

These  operations  were  done  both  at  casualty  clearing  sta- 
tions and  field  ambulances,  but  the  best  method  of  opera- 
tive treatment  was  as  yet  undeveloped,  and  the  result  was 
that  many  septic  complications  were  seen  at  the  base.  Next, 
it  was  noticed  at  the  base  that  cases  which,  from  force  of 
circumstances,  arrived  there  unoperated  upon,  did  better 
than  those  operated  on  at  the  front.  This  was  attributed 
at  first  to  faulty  technique,  and  within  limits  this  criti- 
cism was  just,  as  the  right  operation  was  as  j^et  undevel- 
oped, both  at  the  base  and  the  front. 

The  observation  was  next  made  that  if  patients  were  kept 
quiet  at  the  place  where  they  were  operated  upon  they  did 
well,  while  cases  operated  on  and  apparently  doing  well 
were  reported  to  have  arrived  in  bad  condition  at  the  base 
when  evacuated  early. 

It  thus  became  obvious  that  there  were  two  reasons  for 
head  cases  doing  badly:  (1)  The  want  of  a  good  operation, 
(2)  early  evacuation  of  cases  well  operated  on. 

There  tvere  then  two  alternatives:  The  cases  must  he 
either  operated  on  at  the  front  and  kept.,  or  else  evacuated 
as  soon  as  possible  to  the  base  before  operation;  a  patient 
must  not  be  operated  upon  and  evacuated  forthwith.  Two 
procedures  Avere  therefore  adopted.  In  times  of  pressure 
head  cases  were  cleaned  up  and  sent  to  the  base  at  once, 
provided  they  were  fit  to  travel,  and  in  quiet  times  they 
were  operated  on  and  kept  at  rest  at  a  casualty  clearing 
station  for  a  week  or  ten  daj^s.  Even  this  period  of  rest 
after  operation  proved  too  short,  though  the  results  were 
better  than  in  earlier  evacuation. 

The  next  step  was  the  establishment  of  special  hospitals 
for  head  cases  at  the  front.  Advantage  was  taken  of  the 
fact  that  a  head  case  before  operation  traveled  well,  and 
the  special  hospitals  were  placed  in  the  back  part  of  an 
army  area.  These  hospitals  were  never  subjected  to  the 
sudden  pressure  that  may  fall  on  an  advanced  casualty  sta- 
tion, and  consequently  the  cases  could  remain  there  for  a 
long  time.  By  this  means  patients  experienced  the  advan- 
tages both  of  early  operation  and  prolonged  rest.  The 
actual  method  of  evacuation  is  as  follows:  The  patients 
are  brought  from  the  trenches  to  the  casualty  clearing  sta- 
tion as  rapidly  as  possible.  Here  they  are  examined  and 
dressed.  If  the  pulse  is  slow  they  are  sent  on  to  the  special 
hospital.  If  the  pulse  is  rapid  they  are  put  to  bed  and 
evacuated  later,  should  they  improve.  No  special  attention 
is  paid  to  the  type  of  wound — reliance  is  placed  on  the  slow 
pulse  as  a  sign  that  the  patient  will  bear  the  journey. 


154  WAR   SURGERY   OP   THE    NERVOUS   SYSTEM. 

The  type  of  operation  that  has  eventually  been  found 
most  beneficial  has  been  arrived  at  after  many  changes. 
Workers,  comparatively  far  apart  and  not  in  direct  com- 
munication, have  evolved  very  much  the  same  operation.  At 
the  front  a  small  conservative  operation  was  formerly  prac- 
ticed which  experience  has  shown  to  have  been  a  little  too 
limited  in  scope.  At  the  base  there  were  two  schools — one 
favored  an  extensive  removal  of  bone  and  a  scalp  flap,  the 
other  an  enlargement  of  the  scalp  wound  and  a  limited  re- 
moval of  bone.  Gradually  the  types  of  operations  have  ap- 
proximated. It  has  been  found  that  the  removal  of  bone 
sufficient  to  expose  half  an  inch  square  (1.27  cm.)  of  un- 
injured dura  is  best  suited  to  most  cases.  Opinions  still 
differ,  perhaps,  as  to  the  comparative  merits  of  making  a 
flap  or  enlarging  the  scalp  wound.  On  the  whole,  the  flap 
is  the  best  as  a  routine,  unless  the  wound,  as  in  the  ca  je  of  a 
horizontal  one,  is  so  situated  as  to  compel  the  use  of  a  very 
large  one. 

.  The  recognition  of  the  fact  that  a  slow  jndse  is  not  'neces- 
sarily a  syrrvptom  of  compression  (for  it  may  occur  with  a 
wide  exposure  of  the  brain),  and  that  the  symptoms,  par- 
alytic and  otherwise,  are  not  due  to  depression  of  fragments 
but  to  a  destruction  or  commotion  of  the  brain  matter  which 
is  not  remediable  by  operation,  has  also  had  an  effect  upon 
procedure.  In  the  first  place,  a  slow  pulse  is  welcomed  as 
a  sign  that  recovery  may  follow,  and  it  is  not  taken  as  a 
sign  that  operation  is  urgently  needed,  but  rather  th  t  it  is 
worth  doing.  The  recognition  that  depression  of  fragments 
is  not  the  usual  cause  of  the  sym^ptoms  has  also  done  aumy 
with  the  notion  that  their  removal  must  he  imm-'diately 
undertaken . 

It  is  true  that  the  sooner  a  dirty  wound  is  cleaned  up  the 
better,  but  immediate  operation  is  in  many  head  cr  3^  fol- 
lowed by  a  great  drop  in  blood  pressure,  so  that  so'tu"  deloAj 
may  he  actuaUy  beneficial  on  this  account,  and  Col.  Sargent 
has  pointed  out  that  for  at  least  ^^  hours  after  iujiipy  the 
hrain  is  liable  to  be  osdematous^  and  to  extr^ide  unduly  if 
operated  on  tohile  in  this  condition.  A  moderate  delay  has 
also  been  said  to  do  good  in  that  it  allows  adhesions  to  form, 
betweeni  the  dura  and  the,  pia  mater .^  thus  lessening  the  chance 
of  a  spread  of  infection  over  the  brain  surface. 

At  the  same  time  that  the  best  type  of  operation  as  regards 
the  scalp  and  bonj^  defect  was  being  evolved  manv  other 
points  were  in  the  process  of  settlement. 

1.  Excision  of  the  wound  was  soon  decided  on. 

2.  There  v^as  at  first  considerable  discussion  as  to  h  w  far 
the  brain  should  be  explored  for  bone  fragments  on  tie  one 
hand  and  the  projectile  on  the  other.  Eveiy  one  was  greed 
that  an  X-ray  picture  had  become  a  necessity,  and  the  opinion 
was  gradually  formed  that  a  limited  and  intelligent  -earch 
for  bony  fragments  and  other  foreign  bodies  was  ber  ^ficial, 
but  that  attempts  to  reach  a  missile  which  was  dee^^  '"  em- 
bedded in  the  brain  was  not  justifiable.  Eesults  seen  t^  have 
proved  the  correctness  of  this  line  of  treatment,  fo'-  frag- 


FOBEIGN    WAR    LITERATUEE.  155 

ments  of  shell  are  reported  to  have  caused  little  trouble  pro- 
vided their  weight  was  not  enough  to  cause  pressure  on  the 
sui-rounding  brain  during  movements  of  the  patient. 

3.  The  fact  that  many  patients  with  head  wounds  suffered 
from  septic  complications,  and  the  general  demand  for  the 
drainage  of  all  wounds,  led  at  first  to  the  employment  of 
drainage  in  most  cases  of  cranial  surger}^  not  only  of  the 
scalp  but  of  the  brain  also.  The  results  of  drainage  of  the 
brain  were  not  satisfactory^,  and  gradually  it  was  aban- 
doned, at  any  rate  as  a  primary  measure.  The  introduction 
of  tubes  was  first  omitted,  and  subsequently  systematic  at- 
tempts were  made  to  cover  in  the  exposed  brain,  the  scalp 
b^ging  brought  together  over  the  defect  in  the  bone  and  dura, 
either  by  simple  suture,  pericranial  flaps,  or  relieving  in- 
cisions formed  by  undercutting  the  scalp.  A  drain  intro- 
duced under  the  scalp  is  still  generally  employed.  This 
covering  up  of  the  brain  seems  to  have  been  a  decided  suc- 
cess, and,  although  septic  complications  are  still  too  often 
met  with,  they  are  less  frequent  than  in  former  times.  There 
has  consequently  been  a  great  decrease  in  the  number  of 
cases  of  hernia  cerebri. 

4.  There  is  still  some  difference  of  opinion  as  to  Avhether 
small  cranial  depressions  and  linear  fractures  with  slight 
inequality  of  surface,  uncomplicated  by  symptoms,  should 
be  operated  on  in  the  first  instance. 

5.  Most  surgeons  have  accepted  the  recommendation  of 
Sargent  and  Gordon  Holmes  that  depressed  fractures  over 
the  longitudinal  sinuses  should  be  left  alone  in  the  first 
instance. 

6.  Most  operators  are  of  the  opinion  that  the  dura  mater 
should  not  be  opened  if  found  intact.  The  recognition  that 
true  compression  of  the  brain  is  seldom  seen  has  helped  the 
formation  of  this  opinion. 

7.  A  general  anesthetic  may  with  advantage  be  replaced 
by  the  local  use  of  novocain  and  adrenalin.  If  this  method 
is  adopted  the  patient  is  given  either  hyoscine  and  mor- 
phine or  omnopon  and  scopolamine  an  hour  before  the 
operation. 

Thus,  by  careful  individual  observation,  and  by  the  com- 
parison of  results,  a  method  of  treatment  has  been  evolved 
which  is  applicable  to  all  cranial  Avounds,  and  capable  of 
modification  in  individual  cases.  It  may  be  summarized  as 
f  olloAvs : 

A  primary  cleansing  of  the  wound.  The  transmission  of 
the  patient  as  soon  as  possible  to  the  hospital  where  he 
Avill  convalesce.  The  taking  of  X-ray  pictures.  The  excision 
of  the  scalp  and  bone  wound.  A  limited  and  careful  removnl 
of  foreign  bodies.  The  covering  of  the  exposed  brain.  The 
closure  of  the  wound,  with  superficial  draining,  and  a  pro- 
longed rest  in  bed. 

FRENCH  SCHOOL. 

The  school  of  French  surgeons  are,  on  the  whole,  more  inclined 
than  the  English  to  view  head  injuries  in  the  light  of  demanding 


156  WAR   SUEGEEY   OF    THE    NEEVOUS    SYSTEM. 

immediate  and  radical  operative  treatment.  It  is  easier  to  get  a 
composite  notion  of  French  than  of  English  war  surgery,  because 
at  the  last  French  Congress  {Bull,  et  Mem.  de  la  Soc.  de  Chir.  de 
Paris,  1916-17)  the  various  French  surgeons  recorded  their  views 
very  clearly.  By  way  of  resume,  we  present  a  digest  of  these  views, 
made  by  Maj.  Tarnowsky. 

French  School  (Symposium  presented  and  resolutions  passed  hy  the 
Societe  de  Chirurgie,  Paris). 

All  head  injuries  should  be  carried  from  the  place  where 
they  fell  to  the  place  where  they  can  be  operated  upon  as 
rapidly  as  compatible  with  the  military  necessities  of  the 
moment. 

All  head  injuries  should  be  explored  immediately  upon 
arrival  at  the  designated  hospital,  regardless:  Of  the  hour 
of  arrival,  of  the  date  and  hour  of  the  wound,  of  the  state- 
ments on  the  diagnosis  tag,  of  the  clean  appearance  of  the 
dressing,  or  of  the  patient's  state  of  fatigue. 

Head  injuries  shoidd,  whenever  possible,  be  transported 
directly  from  the  battle  field  to  the  evacuation  hospital,  be- 
cause— 

{a)  Once  operated  upon,  they  should  not  be  subjected  to 
further  transportation  until  they  are  convalescent; 

(h)  Because  field  ambulances  and  field  hospitals  are 
within  range  of  artillery  fire  and  the  noise  and  concussion 
are  very  detrimental  to  such  cases. 

If  primarily  evacuated  to  a  field  ambulance  or  field  hos- 
pital, the  wound  should  be  prepared  surgically  (shaving, 
scrubbing,  trimming,  and  dressing)  before  further  evacua- 
tion to  the  rear. 

Eacliography  is  of  inestimable  value,  but  a  temporary 
breakdown  of  the  apparatus  should  not  deter  the  the  sur- 
geon from  immediate  exploration. 

French  surgeons  strongly  advocate  Tr.  iodi  and  ether  in 
the  surgical  preparation  of  the  case. 

Head  injuries  should  reach  the  operative  table  from  two 
to  six  hours  after  being  injured. 

GENERAL  TREATMENT  OF   CRANIAL  INJURIES. 

1.  Whenever  available  the  skiagraph  should  be  used  in 
order  to  determine  the  type  of  fracture  and  the  presence  or 
absence  of  missiles. 

2.  Thorough  preparation  of  the  surrounding  area,  care- 
fully protecting  the  wound  from  further  contamination. 

3.'  Eemoval  of  all  devitalized  and  lacerated  soft  tissues. 

4.  Eemoval  of  all  small  or  sharp-pointed  fragments  of 
bone  and  preservation  of  large  fragments. 

5.  If  the  dura  is  intact  and  no  focal  symptoms  have  de- 
veloped, leave  it  alone  and  close  the  wound  after  replac- 
ing all  large  bone  fragments. 

'6.  If  the  dura  is  torn  and  the  skiagram  reveals  the  pres- 
ence of  spicules  of  bone  or  of  one  or  more  missiles,  gentle 


FOREIGN   WAR  LITERATURE.  157 

exploration  of  the  lacerated  brain  tract  with  the  gloved 
finger  and  removal  of  the  foreign  bodies  can  not  further 
traumatize  the  tissues. 

7.  The  giant  magnet  is  often  useful  in  the  removal  of 
metal  fragments  (except  copper).  Unless  the  exact  angle 
of  penetration  of  the  missile  is  recognized  and  the  magnet  is 
so  manipulated  as  to  draw  the  missile  out  along  this  same 
angle,  considerable  additional  trauma  to  brain  tissue  may 
ensue.  The  weight  and  bulk  of  the  magnet  also  make  it 
difficult  to  keep  in  the  zone  of  the  ad\'anee. 

8.  Severe  hemori-hage  or  persistent  oozing  from  one  of  the 
main  branches  of  the  middle  meningeal  hemorrhage  will  re- 
quire doable  li gating  with  fine  catgut.  Persistent  oozing 
from  the  pia  or  arachnoid  is  readily  controlled  by  appljdng 
small  pieces  of  muscle  tissue. 

9.  Dural  defects  should  be  closed  by  pieces  of  fascia  or 
dental  rubber. 

10.  Intradural  drainage  should  not  be  resorted  to. 

11.  Wherever  possible  the  wound  should  be  sutured,  leav- 
ing a  small  drain  extending  to  the  meninges. 

12.  The  dressings  should  only  be  changed  when  they  are 
saturated  or  the  secretions  have  dried  up,  making  the  dress- 
ing uncomfortable. 

INDICATIONS  FOR  TREPHINING. 

1.  No  obvious  signs  of  depressed  fracture,  but:  {a)  En- 
trance and  exit  wounds  are  far  distant  from  one  another. 

(5)   Patient   unconscious   at  time  he   received  his   injury. 

(f?)  Persistent  headaches  or  giddiness,  {d)  Fracture  of 
outer  table  without  depression  of  same. 

2.  Depressed  fractures  without  injury  to  the  dura. 

3.  Fractures  with  injury  to  the  dura. 

tt.  Fractures  wdth  injury  to  the  dura  and  presence  of  a  for- 
eign body. 

Should  hony  fragments  he  replaced? 

Small,  sharp,  irregular  fragments  should  never  be  re- 
placed, as  they  tend  to  shift  about  and  traumatize  the  dura. 
Large  depressed,  fairly  even  fragments  should  have  their 
sharp  edges  trimmed  off  and  may  then  be  sterilized  by  boil- 
ing (or  immersion  in  ether)  before  being  replaced. 

If  a  trephine  has  not  been  used,  punch  a  circular  opening 
through  the  most  dependent  portion  of  the  fragment  for 
drainage.  The  skin  flap  will  keep  the  bone  in  its  proper 
position.  The  advantages  of  replacing  such  pieces  of  bone 
are: 

1.  Pretention  of  hernia  cerebri. 

2.  Scaffolding  over  which  bony  or  fibrous  cells  proliferate. 
Should  the  intact  dura  he  incised? 

(a)   Never  if  normal  colored  and  pulsating  normally. 

(h)  Invariably,  if  the  surface  of  the  dura  is  decidedly 
cloudy  or  blackened,  tense,  and  nonpulsating,  or  it  presents 
a  circumscribed  loss  of  elasticit}^    (unequal  tension).     One 


158  WAR   SUEGERY   OF    THE    NERVOUS  SYSTEM. 

will  invariably  find  a  hematoma  or  a  contused  brain  area  or 
both  in  such  cases. 

Should  a  torn  dural  opening  he  enlarged? 

Yes;  invariably.  Enlarge  the  cranial  opening  if  neces- 
sary in  order  to  expose  normal  dura.  Make  a  semilunar  in- 
cision through  dura  beyond  the  traumatized  area;  remove 
all  lacerated  dura.  After  completing  the  operation  cover 
the  dural  defect  by  means  of  {a)  fascia  lata  (best)  ;  {h) 
dental  rubber. 

Eemember  that  a  piece  of  fascia  as  large  as  the  palm  of 
the  hand  will  contract  down  to  one-half  or  even  one-third  of 
its  normal  size.  It  should  either  be  tucked  in  under  the  bone 
or  lightly  anchored  to  the  dura  with  very  fine  interrupted 
catgut  sutures. 

Dental  rubber  makes  an  excellent  nonirritating  protec- 
tive membrane;  it  has  also  been  used  to  cover  peritoneal 
defects  and  contused  arterial  or  venous  walls  (Matas). 

What  are  the  hest  methods  for  controlling  intracranial 
hemorrhage  f 

(a)  Pieces  of  muscle  (autogenous)  applied  directly  to 
the  bleeding  surface  without  making  undue  pressure. 

(h)  Coagulen  Kocher-Fonio  5  per  cent  solution  in  sterile 
water,  boiled  not  to  exceed  five  minutes  and  freshly  pre- 
pared. 

Having  enlarged  the  dural  womid,  lohat  further  steps 
are  necessary  f 

(a)  Eemoval  of  blood  clots. 

(b)  Trimming  of  lacerated  brain  tissue. 

(c)  Removal  of  bone  spicula?,  pieces  of  cloth,  dirt,  etc. 

(d)  Search  for  and  removal  of  metallic  foreign  bodies 
which  have  been  previously  localized  hj  the  X-ray. 

Immediate  removed  of  foreign  bodies  is  justified  because : 
{a)   Track  through  brain  tissue  is  already  present, 

(b)  No  further  injury  to  brain  tissue  need  be  made. 

(c)  If  wound  is  large,  sepsis  is  already  present. 

(d)  Abscess  has  not  formed. 

Secondary  (late)  removal  of  a  foreign  body  presents  the 
following  disadvantages  : 

(a)   Exploring  through  scar  tissue. 

(6)   Additional  laceration  of  brain  tissue. 

(c)  Often  have  to  operate  in  an  infected  area  (abscess, 
etc.),  with  danger  of  dissemination  of  the  infection. 

(d)  The  presence  of  a  metallic  body  within  the  cranial 
cavity  is  a  constant  menace  to  the  patient. 

TECHNIQUE  OF  REMOVAL. 

(a)  Use  all  proper  means  of  localizing  the  foreign  body 
by  means  of  the  X-ray.  Of  especial  importance  is  an  exact 
estimation  of  the  depth  of  the  object  from  the  surface. 

(b)  Gently  explore  the  sinus  leading  to  the  object  with 
the  index  finger  of  left  hand;  locate  the  object  with  tip  of 
finger. 


FOREIGN    WAR  LITERATURE.  159 

(c)  Pass  a  small  spoon  (gallstone  scoop)  alongside  finger 
and  engage  foreign  body  in  the  scoop. 

(d)  Withdraw  finger  and  scoop  simultaneously,  with  the 
foreign  body  between  the  two.  This  minimizes  traumatism 
of  brain  tissue. 

(e)  Should  the  metallic  body  be  embedded  in  bone,  gently 
push  aside  brain  tissue  by  means  of  two  or  three  groove 
directors,  thus  enlarging  the  sinus.  Introduce  straight  or 
curved  forceps  and  endeavor  to  loosen  the  object.  If  suc- 
cessful, withdraAv  forceps  and  proceed  as  in  C.  D.  If  not 
successful,  a  small  chisel  and  hammer  may  be  necessary  in 
order  to  free  the  object. 

/Should  intracereln'al  drainage  he  used? 

No.  It  is  dangerous  and  always  irritating.  Extradural 
wicks  may  sometimes  be  used.  Drainage  from  skin  to 
trephine  opening  is  commonly  used  and  maintained  until 
all  danger  of  sepsis  is  past.  Drains  should  only  be  changed 
on  definite  clinical  indications.  Extradual  wicks  should 
be  renewed  every  second  or  third  day. 

Late  comjjlications  in  head  injuries  usualy  caused  hy : 

(a)   Latest  activation  of  an  encysted  abscess. 

(6)   Exuberant  bony  callus  causing  pressure  symptoms. 

{c)  Meningeal  adhesions  or  scar  tissue  within  brain 
substance,  producing  circulatory  disturbances. 

The  manifestations  are  innumerable  and  the  treatment 
pertains  entirely  to  the  base  hospitals.  The  French  Army 
surgeons  recommend  that  a  trephined  soldier  should  never 
be  sent  back  to  the  firing  line. 

CRANIOPLASTY. 

Cranioplasty  is  indicated  in  all  large  cranial  defects  Avhen- 
ever  a  tendenc}^  to  herniation  of  type  {h)  manifests  itself. 
As  it  is  best  to  delay  this  operation  in  order  to  be  certain 
that  no  nidus  of  infection  lurks  behind  or  that  a  spicule 
of  bone  has  not  been  missed,  this  operation  will  only  ex- 
ceptionally be  performed  in  the  advanced  hospitals. 


The  question  of  anesthesia  has  in  a  measure  settled  itself,  owing 
to  the  fact  that  one  large  group  of  head  injuries  are  followed  by 
such  deep  unconsciousness  that  no  anesthetic  is  necessary,  and  an- 
other group  lends  itself  admirably  to  local  anesthesia  by  virtue  of 
a  more  or  less  profound  obtunding  of  sensation  consequent  upon 
the  injury.  A  third  group  requires  one  of  the  volatile  general 
anesthetics,  either  as  an  adjuvant  to  local  anesthesia,  or  used  alone. 
Both  the  English  and  French  use  chloroform  more  commonly  than 
do  American  surgeons,  and  judgin,g  from  the  literature,  neither  the 
English  or  the  French  have  adopted  intratracheal  anesthesia,  which 
has  become  so  popular  in  America   in  operations  upon  the  head. 


160  WAR   SURGERY   OF   THE    NERVOUS  SYSTEM. 

This  type  of  administration  of  ether  lessens  the  duration  of  post 
anesthetic  vomiting  and  is  particularly  convenient  in  that  it  re- 
mo-s^es  the  anesthetist  from  close  proximity  to  the  field  of  operation. 
The  division  of  head  surgery  in  the  expeditionary  American  hospital 
will  be  equipped  with  intratracheal  anesthesia  apparatus. 

The  following  abstracts  of  articles  by  Quenu,  Couteaud  and 
Bellot,  and  Charles  and  Charrier  discuss  the  subject  of  anesthesia.  A 
fair  test  of  ethyl  chloride  in  America  may  be  said  to  have  dem- 
onstrated that  this  anesthetic  is  far  from  being  as  safe  as  its  ad- 
vocates thought,  and  it  will  probably  be  used  in  the  war  zone  rarely, 
and  then  with  great  caution.  Chloroform  has  been  in  favor  largely 
because  of  its  rapidity  of  action  and  the  difficulty  of  securing  a  suf- 
ficient supply  of  ether  in  the  war  zone. 

Quenu,  J.:  Local  Anesthesia  at  the  Surgical  Ambulance  (Kuues- 
thesie  Local  en  Cliirurgie  Crunienne).  Paris  Medicale,  Sept.  9, 
1916,  p.  229. 

From  a  point  of  view  of  anesthesia,  Quenu  classifies  his 
cases  in  three  groups : 

1.  Those  in  whom  coma  is  complete  are  operated  without 
any  anesthesia. 

2.  Those  who  are  in  a  stage  of  excitement  and  can  not  be 
reasoned  with  are  given  either  ether  or  chloroform. 

3.  The  other  cases  are  operated  under  local  anesthesia. 

It  is  not  always  easy  to  distinguish  between  group  2 
and  group  3,  and  it  very  frequently  happens  that  the  op- 
eration is  started  with  local  anesthesia  and  finished  under 
general  anesthesia.  The  extent  of  the  cranial  injury  never 
serves  as  a  deterrent  to  the  use  of  local  anesthesia,  nor  does 
the  fact  that  the  cranium  is  wounded  in  several  places.  The 
local  anesthesia  used  as  a  rule  is  one-half  per  cent  fresh 
solution  of  novocaine  to  which  adrenalin  is  added  in  the 
proportion  of  25  drops  to  100  drachms. 

The  technique  employed  is  the  ordinary  one  of  blocking- 
off  the  operative  area  by  a  wide  ring  of  infiltration.  Aside 
from  occasional  vomiting  during  the  operation  not  an  im- 
pleasant  accident  nor  incident  has  been  encountered. 


Couteaud  and  Bellot:  Injuries  of  the  Skull  by  Projectiles  (De.s 
traumatisiiies  ci'aniens  par  projectile.s  de  guerre).  BitJL  et  mem. 
Soc.  de  chir.  de  Par.,  1915,  xli,  1110. 

The  authors  give  the  histories  of  29  cases  of  gunshot  in- 
juries of  the  skull  operated  upon  by  them.  Sixteen  of  them 
were  simple  penetrating  wounds,  in  8  the  bullet  had  passed 
entirely  through  the  skull,  and  in  5  the  bone  had  simply  been 
pushed  in  on  the  brain,  without  perforation  of  the  dura 
mater.  In  most  of  the  penetrating  wounds  only  frag- 
ments of  bone  were  found  in  the  brain ;  the  bullets  had  not 
lodged  in  the  brain.  In  such  cases  the  bone  fragments  should 
be  carefully  removed   and  the  wound  drained,  but  there 


FOEEIGN   WAR  LITEEATUKE.  161 

should  be  no  probing  for  foreign  bodies.     It  is  only  rarely 
necessary  to  extract  a  bullet  from  the  brain. 

All  of  the  cmthors'  operations  v;ere  performed  under  local 
anesthesia.  They  used  a  mixture  of  one  part  of  0.5  per  cent 
cocaine  and  two  parts  of  0.5  per  cent  stovaine,  with  a  few 
drops  of  adrenalin  added.  In  addition  to  the  avoidance  of 
surgical  shock  and  vomiting  after  the  anesthetic,  local  anes- 
thesia allows  the  patient  to  make  certain  movements  and 
responses  that  are  of  assistance  to  the  operator.  Ten  of  the 
29  patients  died,  a  mortality  of  34.5  per  cent.  Fifty  per 
cent  of  the  patients  Avith  bullets  passing  entirely  through  the 
brain  died.  All  except  one  of  the  patients  who  died  were  in 
very  bad  condition  when  operated  upon;  they  were  either 
in  pronounced  coma  or  meningo-encephalitis  had  already 
begun.  In  the  cases  where  there  was  loss  of  substance  in  the 
parietal  lobes  there  was  paralysis,  but  in  the  injuries  of  the 
frontal  lobes  there  were  scarcely  any  cerebral  symptoms  and 
the  patients  all  regained  a  normal  psychic  condition. 


Carles,  J.,  and  Charrier,  A.:  General  Anesthesia  with  Ethyl  Chlo- 
ride in  Military  Surgery  (r/nnestlit'Sie  irenerale  au  clilorure 
fV^tbyle  et  la  cliirui-eie  de  .snerre).     Proy.  tncd..  1!)1.5,  xlii,  748. 

The  authors  find  that  ethyl  chloride  anesthesia  is  quite  as 
valuable  in  operations  of  45  minutes'  duration  as  in  those 
of  5  minutes,  though  it  has  ordinarily  been  used  heretofore 
only  in  very  short  operations.  It  is  particularly  valuable  in 
military  surgery  because  of  the  saving  of  time.  It  only  takes 
from  a  few  seconds  to  two  minutes  for  the  patient  to  become 
anesthetized  and  about  the  same  time  for  him  to  awake  from 
the  anesthetic.  The  toxic  action  is  very  slight;  there  is 
seldom  vomiting,  and,  if  any,  it  is  much  milder  than  after 
chloroform  or  ether;  albuminuria  seldom  follows,  and,  if  it 
does,  it  is  slight  in  degree.  This  makes  it  particularly  valu- 
able in  cases  of  shock,  feeble  pulse,  etc.  They  have  used  this 
form  of  anesthesia  in  200  of  700  cases  operated  upon  during 
the  past  five  months.  In  administering  it  several  cubic  centi- 
meters should  be  given  at  first  to  obtain  complete  anesthesia ; 
after  that  about  0.5  ccm.  every  three  or  four  minutes. 
The  three  or  four  respirations  of  pure  air  when  the  mask 
is  raised  to  give  the  ethyl  chloride  are  generally  sufficient  to 
prevent  asphyxia.  There  is  no  danger  of  heart  failure,  as 
with  chloroform,  and  in  the  rare  cases  where  there  is  diffi- 
culty in  respiration  a  few  movements  of  artificial  respiration 
generally  restore  the  patient. 

Though  av algesia  is  perfect  the  relaxation  of  the  'muscle 
is  not  so  complete  as  with  ether  or  chloroform.,  so  thr.t  the 
latter  anasthetics  are  still  to  be  preferred  for  long  and  deli- 
cate abdominal  operations,  but  in  others  ethyl  chloride  could 
be  substituted  with  advantage. 

137G4— 37 11 


162  WAR    SUEGEEY   OF    THE    NERVOUS    SYSTEM. 

The  following  four  abstracts  by  Lapointe,  Chavannaz,  Latarjet, 
and  Gayet  all  deal  with  the  treatment  of  head  injuries  in  the  zone 
of  advance.  This  is  the  field  that  furnishes  so  much  debate  regard- 
ing immediate  operation  versus  transport  back  to  better  equipped 
stations.  It  is  interesting  to  note  that  these  four  operators  are 
unanimous  in  their  advocacy  of  immediate  operation,  though  none  of 
them  perform  extensive  or  radical  operations. 

Lapointe,  A.:  Operative  Treatment  of  Injuries  of  the  Skull  in  an 
Ambulance  at  the  Front  (Le  traitement  operatoire  ties  blossnres 
(lu  crane  dans  une  ambulance  de  Tavant).  J.  de  chir.,  liJh"), 
xiii,  241. 

Lapointe  reports  127  cases  of  injury  of  the  skull  operated 
on  in  his  ambulance.  He  practiced  early  and  sj^stematic 
operation  in  all  cases,  excluding  only  those  that  Avere  so 
nearh^  dead  that  there  was  no  hope.  He  made  a  crucial  in- 
cision in  the  scalp  wound,  examined  for  fractures,  removed 
any  fragments  of  bone,  irrigated  with  hydrogen  peroxide, 
and  dressed  with  iodoform  gauze.  Trephining  was  neces- 
sary only  in  comparatively  few  cases. 

He  divides  the  cases  into  three  classes:  (1)  Those  with 
superficial  injuries,  with  or  without  injury  of  the  dura 
mater;  (2)  those  in  which  the  projectile  had  passed  entirely 
through  the  head;  and  (3)  those  in  which  the  projectile  had 
entered  and  lodged  in  the  brain. 

There  were  47  cases  of  superficial  injury  without  i^enetra- 
tion  of  the  dura  mater;  7  of  these  died,  one  from  a  cause  in- 
dependent of  the  skull  injury,  leaving  a  mortality  of  13  per 
cent.  The  mortality  in  the  48  cases  with  perforation  of  the 
dura  was  56  per  cent,  or,  eliminating  the  very  bad  cases, 
which  would  have  died  anyway,  51  per  cent.  Infection  was 
the  usual  cause  of  death.  Of  the  7  cases  in  which  the  bullet 
passed  entirely  through  the  head,  6  died  and  the  1  who  re- 
covered was  left  with  a  paraplegia. 

There  were  25  cases  in  which  the  bullets  had  lodged  in  the 
brain.  Operation  in  these  cases  was  limited  to  extracting 
fragments  and  trying  to  limit  infection;  the  projectiles  were 
not  removed;  nevertheless  the  mortality  was  56  per  cent. 
Moreover,  those  who  recovered  are  still  subject  to  the  danger 
of  late  infection  from  the  projectiles.  Lapointe  thinks  that 
as  a  result  of  the  present  war  the  idea  of  leaving  such  pro- 
jectiles will  probably  be  reversed,  and  it  will  be  thought  best 
to  make  immediate  roentgen  examination  and  remove  them. 

His  experience  shows  the  comparative  harmlessness  of 
extradural  injuries  and  the  terrible  mortality  of  intradural 
ones.  The  mortality  of  all  the  introdural  injuries  together 
was  58.75  per  cent.  Part  of  this  high  mortality  was  due  to 
the  fact  that  it  was  impossible  to  operate  early  enough;  only 
22  of  their  127  cases  were  operated  on  the  day  of  the  injury ; 
the  remainder  was  due  to  the  insufficient  first  aid  given. 
Scarcely  any  of  the  wounded  men  had  been  shaved  around 
the  wound  JDefore  the  first  dressing  Avas  applied.  The  im- 
portance of  this  measure  is  shown  by  comparing  the  mor- 


FOREIGN    WAR   LITERATURE.  163 

tality  statistics  of  head  injuries  among  the  Russians,  who 
had  long  hair,  and  the  Japanese,  who  had  their  heads  shaved. 
Better  results  can  only  be  obtained  by  more  efficient  first  aid 
and  earlier  operation. 

Chavannaz,  G.:  Treatment  of  Fractures  of  the  Skull  at  the  Front 

(Sur  le  traitemeut  <le,s  fractures  du  crane  par  urines  a  feu  flans 
le  service  de  I'avant).  Bull,  ct  mdm.  Soc.  de  chir.  de  Par.,  1915, 
xli,  549. 

Chavannaz  gives  brief  histories  of  59  cases  of  fracture  of 
the  skull  operated  upon  by  him;  he  has  had  67  cases  in  all, 
but  the  others  were  too  near  death  when  received  to  be  oper- 
ated upon. 

He  advocates  operation  in  all  cases  of  fracture  of  the 
skull.  If  the  fracture  is  large  the  edges  are  smoothed  off 
with  bone  forceps;  if  the  opening  is  not  large  enough  for 
examination  of  the  wound  a  trephine  is  done;  the  toilette 
of  the  wound  is  carefully  made,  and  bone  splinters  are  looked 
for,  but  sometimes  they  are  overlooked  because  they  have 
penetrated  the  brain  tissue  so  deeply.  Because  of  the  danger 
of  infection  he  touches  the  brain  surface  with  a  gauze  com- 
press slightly  moistened  with  dilute  tincture  of  iodine. 
Drainage  was  maintained  for  48  hours  with  a  rubber  drain ; 
gauze  drains  were  used  only  when  there  were  extensive 
lesions  of  the  intracranial  sinuses.  Unless  the  patients  were 
in  complete  coma  chloroform  anaesthesia  was  given. 

Among  the  59  cases  there  were  26  deaths  and  33  recov- 
eries—that is,  55.91  per  cent  of  cases  were  successful.  The 
patients  were  kept  under  observation  three  weeks  or  more. 
In  7  of  the  cases  there  were  lesions  of  the  intracranial  venous 
sinuses,  one  of  which  was  treated  by  ligation,  the  others  by 
tamponing.  Four  of  these  7  died.  The  accessory  nasal 
sinuses  were  involved  in  6  cases,  and  all  of  them  recovered. 
Two  of  these  patients  also  had  injuries  of  the  eye  which 
necessitated  enucleation.  In  8  of  the  cases  there  was 
paralysis ;  3  of  these  died,  in  2  the  paralysis  disappeared,  in 
2  it  improved  markedly,  and  in  1  it  persisted. 


Latarjet,  A.:  Pathologic  Anatomy  of  the  Immediate  Lesions  in  Pen- 
etrating Cranial  Fractures  Due  to  Projectiles  (Anatomie  patho- 
logique  des  lesions  immediates  dans  les  fractures  penetrantes 
du  crane,  par  projectiles  de  guerre).     Lyon  chir.,  1916,  xiii,  213. 

The  pathological  studies  which  Latarjet  made  immedi- 
ately after  death  in  cases  of  extensive  cranial  fractures  have 
led  him  to  the  conclusion  that  in  the  less  extensive  injuries 
which  are  susceptible  of  recovery  it  is  necessary  to  intervene, 
very  amply  and  without  restriction. 

The  details  of  several  cases  are  given  with  photographic 
illustrations  to  show  the  mechanism  and  consequences  of 
various  types  of  penetrating  fractures.  The  large  experi- 
ence gained  from  the  study  and  results  of  treatment  of  such 
injuries  has  led  Latarjet  to  adopt  the  following  treatment 
in  cases  of  severe  penetrating  cranial  fractures. 


164  WAE    SURGERY   OF    THE    NERVOUS   SYSTEM. 

1.  Very  wide  trepanation,  which  is  not  limited  by  the 
extent  of  lesions  of  the  dura  mater,  but  by  the  extent  of  the 
destructive  cerebral  lesions,  that  is  to  say,  which  extends  2 
or  3  mm.  beyond  the  limit  of  lesions  of  the  soft  meninges. 

2.  Clearance  of  the  cerebral  injured  area;  removal  of  visi- 
ble fragments;  delicate  cerebral  exploration  with  light  tam- 
ponade of  the  lesion  by  a  tampon  saturated  with  weak  iodide 
tincture.    This  tampon  is  allowed  to  remain. 

3.  Insertion  of  a  very  fine  meshwork  saturated  with  iodide 
tincture  between  the  endocranium  and  dura.  When  a  fissure 
exists  this  mesh  is  extended  as  much  as  possible  in  order  to 
establish  a  barrier  between  the  dura  and  the  fissured  in- 
ternal table. 

4.  Between  the  dura  and  the  external  cerebral  face  a  simi- 
lar mesh  is  insinuated.  This  meshwork  excludes  the  ce- 
rebral area  which  is  the  center  of  it  and  fulfills  a  double 
purpose.  It  allows  drainage  of  subarachnoidal  haemorrhage 
and  is  an  obstacle  to  diffusion  from  the  septic  cerebral  area 
into  the  subarachnoidal  spaces  largely  open  to  contact  as 
well  as  tending  to  the  production  of  adherences  which  also 
afford  protection  against  the  spread  of  infection.  The 
meshes  are  resaturated  with  iodide  by  means  of  a  tampon, 
and  are  allowed  to  remain  in  place  until  the  fifth  or  sixth 
day  when  they  are  removed  and  replaced  by  others. 

Since  the  adoption  of  this  method  of  treatment  there  have 
been  no  deaths  from  primitive  meningitis  which  previously 
had  habitually  caused  the  death  of  such  patients  in  the 
course  of  the  second  week.  Latarjet  thinks,  moreover,  that 
the  fear  of  a  later  reproduction  of  encephalitis  is  diminished 
by  the  isolation  of  the  cerebral  substance  from  the  fracture 
and  fissures.  His  procedure  is  the  application  to  the  brain 
of  the  general  rule  of  war  surgery :  To  clear  widely,  to  con- 
vert the  lesion  into  a  surface  wound,  and  to  isolate  the  septic 
area. 

He  reiterates  that  clinical  and  anatomical  results  have 
convinced  him  that  the  extent  of  the  trepanation  must  be 
governed  by  the  extent  of  the  cerebral  lesion  area  and  that 
an  attempt  must  be  made  to  exclude  this  area  by  isolating  it 
from  the  osseous  lesions  and  from  its  communication  with 
the  meningeal  spaces  and  blood  vessels. 


Gayet,  G.:  Surgery  of  Penetrating  Injuries  of  the  Skull  at  the  Front 

(La  chirurgie  des  plaies  penetrantes  du  crane  par  projectiles  de 
guerre  dans  les  ambulances  immobilisees  de  I'avant).  Lyon  dhir., 
1915,  xii,  618. 

The  absolute  rule  in  the  army  corps  in  which  Gayet  has 
worked  is  to  send  all  cases  of  head  injury  as  quickly  as  pos- 
sible to  the  surgical  ambulances.  Automobiles  are  sent  di- 
rectly to  the  dressing  stations  for  them.  Whatever  hour  of 
the  day  or  night  they  come  in,  they  are  immediately  exam- 
ined and  operated  upon.  It  is  generally  agreed  that  the 
prognosis  depends  very  greatly  upon  the  promptness  of  the 
operation.     No  matter  how  slight  the  wound  may  be,  it  is 


FOREIGN    WAR   LITERATURE.  16§ 

opened  up.  Two  cases  are  described  where  there  was  ap- 
parently only  a  very  slight  scalp  wound,  but  when  it  was 
opened  up  the  bone  was  found  to  be  cracked.  If  these 
patients  had  been  allow^ed  to  go  without  operation,  they 
would  have  died  of  meningitis. 

Most  of  the  author's  operations  were  performed  three  to 
six  hours  after  the  injury.  The  objects  of  operation  are  to 
control  hemorrhage  and  prevent  infection.  If  the  dura  is 
found  normal  in  appearance,  it  should  be  left  intact;  but 
if  it  is  ecchymotic  and  does  not  pulsate  normally,  it  should 
be  opened  and  the  brain  examined.  No  probing  should  be 
done  for  deep  projectiles,  but  a  careful  examination  should 
be  made  for  superficial  ones,  and  they  should  be  removed. 

Hemorrhage  from  the  sinuses  is  controlled  by  tampon- 
ing, from  the  meningeal  arteries  by  ligation.  Deep  hemor- 
rhage is  sometimes  difficult  to  control,  but  it  should  be  done 
by  ligation  rather  than  by  pressure  if  possible.  Gayet  does 
not  favor  the  use  of  strong  antiseptics  on  brain  tissue,  but 
iodoform  gauze  may  be  used.  This  should  be  placed  only 
on  the  surface.  Drains  should  not  be  inserted  in  brain  tis- 
sue. The  first  dressing  should  be  left  on  48  hours.  Patients 
with  brain  injuries  should  be  moved  as  little  as  possible. 
They  should  not  be  transported  for  at  least  two  months  if 
it  is  possible  to  keep  them  that  long.  In  the  meantime  they 
may  be  given  treatment  for  any  paralysis  or  aphasia  result- 
ing from  their  wounds. 

Gayet  has  operated  upon  198  cases,  with  100  recoveries, 
76  deaths,  and  22  unknown  results.  The  cases  that  he  calls 
cured  were  under  observation  for  several  weeks,  and  when 
they  were  discharged  the  brain  was  completely  covered  in 
with  epidermis  or  active  granulations.  He  has  heard  from 
five  of  the  worst  cases  after  more  than  six  months  had  elapsed 
and  all  are  alive,  though  two  are  under  treatment  for  slight 
aphasia  or  paralysis. 


Temoin  emphasizes  the  dangers  of  tangential  wounds,  and  in  so 
far  he  is  in  agreement  with  the  conservative  English  school.  He 
recommends  trephining  in  every  case  of  tangential  wound  accom- 
panied by  the  minutest  fissuring  of  the  skull,  owing  to  the  frequency 
with  which  fissuring  and  fracturing  of  the  inner  table  accompanies 
tangential  wounds. 

Temoin:  Fractures  of  the  Skull  by  Tangential  Shots  (Fractures  du 
^'rane  par  lesion  tangentielle  cle  la  tete).  Bull,  et  mem.  Soc.  de 
chir.  de  Par.  1915,  xii,  1024. 

Temoin  calls  attention  to  the  frequency  with  which  in- 
juries of  the  scalp,  apparently  slight,  are  accompanied  by 
fracture  of  the  skull.  After  having  had  one  or  two  sad 
experiences  in  losing  patients  with  encephalitis  when  they 
had  come  in  with  apparently  only  slight  scalp  wounds  he 
adopted  the  plan  of  opening  up  all  scalp  wounds  freely  and 
examining  the  skull.    If  there  is  the  slightest  fissure  of  the 


166  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

external  table  he  trephines  at  once.  Any  clots  or  fragments 
are  removed  and  a  small  drain  left  in  the  wound.  Among 
33  patients  with  scalp  wounds  treated  in  this  way,  29  were 
found  to  have  fractures  of  the  skull.  All  of  the  23  who  were 
trephined  immediately  after  their  arrival  at  the  hospital 
recovered ;  of  the  5  who  were  not  operated  upon  until  symp- 
toms of  brain  disturbance  developed,  4  died.  Therefore  he 
is  an  ardent  advocate  of  immediate  operation  in  skull  in- 
juries. 

In  the  discussion  Pauchet  pointed  out  that  in  some  cases 
where  there  is  no  true  fracture  but  careful  examination 
shows  an  ecchymosis  of  the  external  table  of  the  skull, 
trephining  will  reveal  the  fact  that  there  is  a  fracture  of  the 
internal  table;  therefore  cases  showing  such  ecchymoses  or 
hemorrhagic  spots  should  be  operated  upon.  Tuffier  agreed 
with  him  in  this  opinion. 


On  the  subject  of  intracranial  and  intracerebral  foreign  bodies 
the  French  are  inclined  also  to  take  a  more  radical  view  than  do  the 
English.  The  following  three  abstracts  illustrate  this  point.  The 
third  abstract  (Villaret  and  Beaulieu)  shows  the  relationship  be- 
tween foreign  bodies  and  the  so-called  late  results  of  head  injuries. 

Abadie:  The  Extraction  of  Intracranial  Projectiles  in  Two  Stages: 
Trepanation  for  Access  After  Radiographic  Location;  Extrac- 
tion Under  the  Radioscopic  Screen  (L'ablation  des  projectiles 
intercrauiens  en  deux  temps ;  trepanation  d'acces  apres  rep§rage 
radiograpliique ;  extraction  sous  I'ecran  radioscopique).  Bull, 
et  m^m.  8oc.  de  chir.  de  Par.,  1916,  xlii,  3. 

Abadie  thinks  that  all  intracranial  projectiles  should  be 
removed  as  early  as  possible.  Where  the  foreign  body  is 
very  distant  from  the  point  of  entry  or  anatomically  placed 
in  such  a  way  that  the  point  of  entry  can  not  be  used  as  an 
approach,  he  uses  the  following  technique.  He  makes  a 
trepanation  at  a  point  selected  on  account  of  its  proximity 
to  the  projectile  and  also  to  the  vessels  and  other  structures. 
The  dura  is  opened  sufficiently  to  permit  the  introduction  of 
a  forceps,  and  the  wound  is  temporarily  dressed.  On  the 
next  clay,  or  the  day  following,  extraction  of  the  projectile 
is  carried  out  under  the  radioscopic  screen,  no  anesthesia 
being  necessary. 

Abadie  considers  that  his  method  of  extraction,  a  day  or 
two  after  the  operatory  incision,  avoids  many  causes  of  pos- 
sible infection,  and  reduces  the  maneuvers  of  extraction  to  a 
minimum. 


Villandre,  C:  Metallic  Intracranial  Foreign  Bodies  Apparently 
Tolerated  (Corps  etrangers  metalliques  iutracraniens  toleres  en 
apparence. )     J.  de  m6d.  et  de  chir.  prat.,  1917,  Ixxxviii,  129. 

Villandre  refers  to  a  recent  report  of  Marie  in  which  he 
referred  to  31  cases  of  wounded  soldiers  who  not  only  re- 
tained a  projectile  in  their  brain  with  no  irritation,  but  in 


FOREIGN  WAR  LITERATURE.  167 

the  majority  of  cases  were  not  even  aware  of  the  presence 
of  the  foreign  body. 

Villandre  does  not  agree  with  Marie's  belief  that  it  is  un- 
necessary to  seek  a  projectile  when  it  is  causing  no  trouble 
and  that  the  presence  of  the  projectile  is  less  dangerous  for 
its  bearer  than  would  be  any  operation  for  its  extraction. 
Villandre  thinks  that  such  tolerance  of  projectiles  is  apimr- 
ent  only,  and  that  at  any  time  grave  complications  may  en- 
sue; that  such  projectiles  still  harbor  microbic  agents,  the 
virulence  of  which  may  be  great  even  after  long  months  of 
aparent  toleration;  and  that  a  av ell-conducted  operation  is 
not  dangerous. 

In  the  author's  service  20  such  cases  with  tolerated  cranial 
projectiles  were  observed.  The  developments  are  shown  in 
the  following  table : 

Number  of  cases  observed 20 

Still  ill  observatioii ^ 

In  which  u  tistula  was  developed ^ 

Accompanied   by   abscess | 

With  development  of  Jacksonian  epilepsy o 

With    hemianopsia ^ 

With  tolerated  projectile  (3  aseptic) o 

With  projectile  not  extracted 1 

Two  of  these  cases  (abscess  cases)  died. 

The  author  believes  that  metallic  foreign  bodies,  whether 
superficial  or  deeply  embedded  in  the  interior  of  the  en- 
cephalic mass,  are  a  permanent  source  of  danger  and  in  the 
majority  of  cases  should  be  extracted  as  rapidly  as  possible. 


Villaret,  M.,  and  Faure-Beaulieu:  The  Grave  Accidents  of  Late 
Appearance  in  Craniocerebral  Wounds  of  War  (Les  accidents 
graves  d'apparition  tardive  chez  les  blesses  de  guerre  cranio- 
cerebraux).  BuU.  ct  mem..  8oc.  med.  d.  hov-  de  Par.,  1916,  xxxii, 
535. 

The  authors  give  particulars  of  27  cases  of  cranial  wounds 
out  of  a  total  of  256  which  have  presented  grave  accidents 
appearing  several  months  after  the  traumas.  These  cases 
are  classified  under  four  headings:  (1)  Late  epilepsy,  (2) 
grave  mental  troubles,  (3)  meningeal  infection  and  abcess 
of  the  brain,  (4)  late  brain  hernia. 

Mental  troubles  and  late  cerebral  hernia  are  exceptional. 
The  most  frequent  and  important  results  are  late  epilepsy 
and  suppurative  meningo-encephalitis.  Meninigitis  and 
suppurative  encephalitis  were  noted  in  four  cases  appearing 
from  two  to  eight  months  after  the  traumas.  The  study  of 
these  cases  has  shown  the  imortant  part  played  by  the  per- 
sistence of  foreign  bodies  and  metallic  debris  in  the  lesion. 
In  the  case  of  late  epilepsy  it  is  most  interesting  from  the 
point  of  view  of  the  lapse  of  time  after  the  trauma.  In  one 
case  this  extended  to  13  months,  but  most  often  it  oscillates 
between  4  and  10  months.  .     .  . 

Most  of  these  cases  have  been  trephined  for  the  primitive 
injury. 


168  WAR   SUEGERY   OF    THE    NERVOUS   SYSTEM. 

The  practical  conclusions  which  the  authors  draw  from 
their  study  of  the  cases  are  that  in  the  case  of  men  trephined 
or  presenting  traces  of  craniocerebral  traumas,  the  future 
prognosis  must  be  reserved  even  in  the  absence  of  flagrant 
symptoms  of  central  nervous  lesions.  Systematic  radiologic 
examination  of  the  cranium  should  always  be  made  to  dis- 
cover metallic  debris  or  osseous  particles;  these  are  foci 
which  provoke  late  grave  results.  Such  men  should  not  be 
returned  to  the  front  but  kept  at  duty  in  the  rear  under 
medical  supervision. 

On  the  subject  of  hernia  and  fungus,  Marchack,  and  also  Leriche, 
emphasize  the  necessity  of  enlarging  the  outlet.  Neither  of  these 
authors  call  attention  to  the  danger  of  breaking  down  meningeal 
adhesions  by  such  operative  attacks. 

Marchack:  Cerebral  Hernia  (Heruies  c^rebrales).  Presse  mM., 
1916,  p.  35. 

Cerebral  hernia  may  be  distinguished  as  occurring  either 
with  or  without  subjacent  abscess.  In  the  first  form  the 
abscess  must  at  once  be  opened  so  that  it  may  not  discharge 
into  the  ventricle.  These  patients  almost  all  succumb  to 
meningocephalitis.  But  the  hernia  without  abscess  is  of 
more  interest  as  it  is  susceptible  of  treatment. 

Marchack  thinks  that  the  cause  of  these  cerebral  herniae 
is  congestive  cedema  of  the  traumatized  brain,  and  that  the 
tumor  projected  across  the  insufficiently  opened  dura  mater 
becomes  strangled  and  adherent  to  the  ring. 

Such  a  hernia  usually  occurs  within  a  few  hours  of  injury. 
It  is  not  due  to  hypertension,  because  its  volume  diminishes 
only  very  slightly  after  lumbar  punctures. 

Probably  one-half  of  those  with  gunshot  cranial  wounds 
show  hernia,  especially  if  the  injury  is  in  the  right  parietal 
region  and  even  if  the  osseous  breach  is  small.  In  wounds 
of  the  frontal  and  occipital  region  hernia  is  rare. 

In  treating  hernia  Marchack  has  tried  all  methods  from 
ablation  by  the  thermocautery  to  simple  compression.  He 
thinks  that  the  treatment  of  choice  is  after  a  certain  period 
to  enlarge  the  strangulating  ring,  remove  bone  fragments, 
etc.,  lavage  with  20  per  cent  formol  and  compression.  In  the 
course  of  treatment  patients  show  crises  of  Jacksonian 
epilepsy,  but  repeated  lumbar  punctures  cause  them  to  dis- 
appear. 

Leriche,  R.:  Pathogenesis  and  Treatment  of  Precocious,  Persistent, 
Cerebral  Hernia  (Pathogeuie  et  traitement  de  la  hernie  cere- 
brale  precoce  persistante).     Lyon  chir.,  1916,  xiii,  448. 

Cerebral  hernia  is  a  frequent  complication  of  cranial 
wounds.  A  number  of  small  hernias  which  follow  trepana- 
tion disappear  spontaneously  without  leaving  any  trace  be- 
hind. Others,  greater  in  volume,  increase  incessantly  and 
death  by  progressive  encephalitis  is  the  customary  termina- 
tion. But  frequently  hernias  are  seen  to  persist  without 
increasing   or    diminishing   in    size,   remaining   stationary 


FOREIGN    WAR   LITERATURE.  169 

while  the  condition  of  the  patient  inii)roves.  If  they  are  left 
untreated  some  may  recover  after  a  long  lapse  of  time,  but  a 
much  larger  number  die  either  from  cerebral  abscess  or 
meningo-encephalitis. 

This  cerebral  hernia  is  generally  considered  to  be  an  indi- 
cation of  a  deep  infection  and  a  fatal  prognosis  is  accepted. 
Leriche,  however,  believes  that  this  pessimistic  view  is  the 
result  of  a  false  idea  of  the  pathogenesis.  In  reality  he  says 
•that  these  early  persisting  encephaloceles  are  frequently 
curable  as  they  are  the  mechanical  translation  of  a  perma- 
nent local  irritation  resulting  from  an  insufficient  trepana- 
tion and  therefore  should  be  treated  by  an  enlargement  of 
the  osseous  breach  until  meningeal  and  cerebral  healthy  tis- 
sues are  met  with. 

The  hernia  is  a  mechanical  phenomena  of  tissue  disorgani- 
zation which  is  aggravated  owing  to  the  strangulation  of 
the  vessels  by  a  very  narrow  bony  ring ;  it  signifies  that  the 
trepanation  has  not  been  wide  enough,  and  that  there  is  still 
a  local  irritating  agent  (fissure,  superficial  foreign  body, 
etc.),  or  a  large  area  of  cerebral  contusion  which  is  not  de- 
compressed. Under  these  circumstances  a  new  very  wide 
trepanation  is  called  for ;  this  is  the  best  method  of  reducing 
the  hernia  and  curing  the  patient.  The  results  obtained  by 
such  methods  for  true  persisting  hernias,  in  the  case  of  pa- 
tients otherwise  in  good  state,  are  such  as  to  suggest  that 
earl}^  retrepanation  is  called  for  in  patients  wdio  show  an 
increasing  hernia  while  the  general  condition  declines. 
Nearly  all  such  patients  die  from  progressive  encephalitis, 
and  it  seems  to  Leriche  that  here  again  the  hernia  is  the 
result  of  an  insufficient  trepanation  for  the  lesions,  although 
often  enough  this  trepanation  is  large.  Moreover,  b}^  mak- 
ing a  very  large  osseous  breach,  perhaps  the  number  of 
deaths  due  to  infection  will  also  be  diminished. 

Leriche  gives  details  and  illustrations  of  many  types  of 
cases ;  considers  the  mechanism  of  recovery  of  hernias  after 
wide  trepanation;  and  gives  the  technical  indications  for 
trepanation  in  case  of  cerebral  fungus. 


The  subject  of  grafting  to  fill  in  cranial  defects  has  been  ex- 
ploited more  extensively  by  the  French  than  by  any  other  surgeons. 
The  following  abstracts  are  fairly  typical  of  many  similar  ones: 

Morestin,    H. :  Cartilaginous    Transplants    in    Reparative    Surgery 

(Les  Transplantations  Cartilagineuses  dans  la  CUirurgie  Re- 
paratice).  Bull.  ct.  Mem.  de  la  Soc.  de  Chit:  de  Paris,  1915, 
xli,  p.  1994. 

Cartilages  of  the  sixth,  seventh,  and  eighth  ribs  are  the 
only  ones  that  can  easily  be  made  use  of.  Resection  of  any 
of  these  cartilages  never  brings  about  any  untoward  conse- 
quences if  attention  is  given  and  if  one  reconstitutes  with 
care  by  layers  of  sutures  the  musciilo-aponeurotic  bed. 
Ea'cu  after  having  entirely  removed  the  three  cartilages 
mentioned,  I  have  never  observed  any  accident  or  incon- 


170  WAR   SUEGERY   OF    THE    NERVOUS   SYSTEM. 

venience  whatever,  and  in  particular  neither  lasting  respira- 
tory trouble  nor  difficulty  on  exertion,  tendency  to  hernia, 
nor  pain. 

Costal  cartilage  easily  lends  itself  to  be  cut  with  a  knife. 
Sheets,  rods,  arcs,  etc.,  can  be  cut  and  fashioned  in  the  form 
for  adaptation  to  their  destination  with  extreme  precision. 
The  surgeon  has  no  need  in  preparing  his  piece  of  prosthesis 
either  of  help  or  special  instruments. 

In  spite  of  this  property  of  adaptation,  cartilage  offers 
very  great  resistance  and  will  take  everywhere  the  place  of 
bony  tissue. 

The  transplanted  fragments  are  really  grafted,  they  live 
their  normal  life,  they  adapt  themselves  with  extreme  rapid- 
ity to  their  new  conditions  of  existence.  And  this  graft 
succeeds  always,  so  to  speak,  whilst  that  of  bone  is  so  diffi- 
cult to  obtain.  The  grafted  cartilage  lives  indefinitely  with- 
out being  resorbed,  without  undergoing  appreciable  diminu- 
tion. The  importance  of  this  may  be  conceived.  The  re- 
sult is  that  in  practice  one  has  not  to  consider  reduction  in 
size  of  the  transplanted  pieces,  and  one  can  and  should  give 
them  their  exact  dimensions. 

Cartilage  may  be  taken  from  another  person  and  may 
have  been  removed  as  long  as  a  month  previously  to  using 
as  a  graft.  Operations  can  often  be  done  under  local  anes- 
thesia. The  cartilage  frequently  remains  slightly  mobile 
on  the  bone,  but  is  adherent  to  the  soft  parts. 

After  removing  the  costal  cartilage  it  is  necessary  some- 
times to  ligate  the  internal  mammary  artery.  After  this 
the  muscular  bed,  the  superficial  aponeurosis,  and  the  skin 
are  sutured. 

In  placing  the  cartilage  the  bony  surfaces  of  the  wound 
must  be  as  free  as  possible  of  oozing  of  blood.  The  differ- 
ent pieces  of  cartilage  should  be  applied  to  one  another  with 
flat  surfaces.  If  bleeding  persists,  drainage  must  be  pro- 
vided for  temporarily  by  leaving  an  opening  in  the  skin 
wound,  which  is  usually  closed  after  24  hours.  As  a  rule, 
the  cartilage  is  retained  in  place  by  being  cut  to  fit  accu- 
rately and  needs  no  other  retention. 

Even  infection  of  the  operative  field  does  not  necessarily 
mean  elimination  of  the  cartilage,  and  it  suffices  to  prevent 
its  loss,  to  reopen  the  wound,  evacuate  the  pus,  and  maintain 
drainage. 


Leclerc,  G.,  and  Walch:  Osseous  Graft  Taken  From  the  Scapula 
to  Replace  Cranial  Loss;  Ivory  Plates  in  the  Repair  of  Cranial 
Losses  (Perte  cle  substance  clu  crane  obliteree  par  un  gi-effon 
osseux  emprunte  fl  I'omoplate ;  deux  observations  cle  prothese 
avec  des  plaques  d'ivoire  pour  reparer  des  pertes  de  substance  du 
crane).     Bull,  et  tn&m.  8oc.  de  chir.,  de  par.,  1916,  xlii,  2021, 

The  above  reports  were  submitted  by  Mauclaire.  In 
Leclerc's  case  the  loss  of  cranial  substance  was  repaired  by 
a  cranioplasty  made  at  the  expense  of  a  bone  graft  borrowed 
from  the  scapula.  The  hole  was  the  size  of  a  5-franc  piece. 
In  the  cases  reported  by  Walch  the  holes  were  approxi- 
mately 5  cm.  by  4  cm.  and  were  repaired  by  ivory  plates. 


FOREIGN    WAR  LITERATXTRE.  171 

Mauclaire  calls  attention  to  the  different  methods  of  re- 
pairing cranial  losses :  periostic,  osteoperiostic,  and  cutaneo- 
periostic  cranioplasty ;  (2)  autoplastic,  homoplastic,  or  het- 
eroplastic osseous  grafts ;  (3)  cartilaginous  grafts;  (4)  trans- 
plants of  macerated,  decalcified,  carbonized  calcined  or  ster- 
ilized bone;  (5)  cranial  prosthetics;  (6)  finally,  in  order  to 
complete  the  repair,  fat,  serous,  and  fibrous  complementary 
grafts. 

All  these  methods  have  given  good  results,  the  cartilagi- 
nous is  the  most  generally  employed  now,  but  time  will  show 
whether  the  cartilage  becomes  ossified. 

Mauclaire  reviews  the  history  of  the  various  procedures 
and  thinks  that  generally  speaking  osseous  and  cartilagi- 
nous grafts  are  preferable  to  prosthetic  procedures  with 
ivory,  metallic,  or  other  plates.  As  regards  functional  re- 
sults the  end  aimed  at  by  the  surgeon  is  not  the  amelioration 
of  encephalic  disturbance,  but  the  protection  of  the  brain 
from  injury.  The  psychic  effect  is  good  because  the  patient 
feels  that  his  brain  is  protected.  The  esthetic  result  is 
equally  satisfactory. 

Keports  submitted  by  Marie,  Claud,  and  Sicard  do  not, 
however,  show  that  in  cases  of  repair  of  osseous  breeches  that 
there  is  any  satisfactory  cerebral  functional  amelioration. 
Thus  in  21  cases  of  repair  on  which  Marie  has  reported  there 
were  6  ameliorations  without  complete  disappearance  of  sub- 
jective disturbance,  12  absolutely  stationary,  and  3  cases  of 
aggravation  of  the  subjective  disturbances.  Moreover,  Mau- 
claire does  not  think  it  wise  when  there  is  a  tendency  to  cere- 
bral hernia  to  close  the  osseous  breech.  If  there  is  hyperten- 
sion of  the  cephalorachidian  fluid  it  is  best  to  defer  repair. 


The  French  have  not  studied  the  effects  of  shell  shock  and  the 
consequent  nervous  phenomena  as  intensively  as  have  the  English, 
but  the  articles  by  Leriche  and  Baumel  serve  to  emphasize  the  value 
of  lumbar  puncture  for  reducing  the  pressure  of  the  cerebrospinal 
fluid  in  those  cases  presenting  marked  symptoms  of  injury  to  the 
central  nervous  system  without  demonstrable  lesions. 

Leriche,  R.:  Nonpenetrating  Injuries  of  the  Skull  by  the  Bursting 
of  Shells,  and  the  Nervous  Lesions  Caused  by  Them  (Des 
petites  plaies  du  crane  par  eclats  cl'obus  et  tie  bombes  sans  pene- 
tration du  projectile  et  des  lesions  nerveuses  qui  les  accompagn- 
ent).    Lyon  cJiir.,  1915,  xii,  293. 

Leriche  gives  an  extensive  study  of  the  subject,  reporting 
the  details  of  87  cases  of  skull  injury  and  11  others  in  which 
there  was  no  direct  wound  but  only  severe  concussion  of  the 
brain  or  spinal  cord  from  explosion  of  shells  or  mines.  He 
has  seen  397  cases  in  which  the  fragment  of  shell  had  appar- 
ently only  bruised  the  scalp.  But  no  matter  how  slight  the 
wound  appears  to  be,  an  exploratory  incision  should  be  made 
in  every  case,  and  if  the  bone  looks  at  all  abnormal  it  should 


172  WAR  SURGEEY   OF    THE    XEEVOUS   SYSTEM. 

be  trephined ;  but  if  the  dura  is  found  intact  it  should  never 
be  incised,  no  matter  how  severe  the  subjacent  hematoma 
and  Contusion  of  the  brain  may  be.  High  pressure  in  the 
spinal  fluid  does  not  distinguish  between  deep-seated  and 
superficial  lesions.  Leriche  w^as  inclined  to  believe  that  it 
did  at  first  but  has  tested  it  thoroughly  and  found  that  it 
did  not.  High  pressure  and  an  abnormal  tint  of  the  fluid 
indicate  the  existence  of  small  foci  of  contusion  of  the  brain, 
due  to  air  concussion  from  the  explosion  of  the  shell  rather 
than  to  the  eifect  of  the  projectile  itself.  Lumhar  puncture 
is  of  great  value  in  treatment. 

In  the  cases  caused  by  concussion  the  pressure  of  the  s,pinal 
fluid  remains  high  for  days  if  puncture  is  not  performed, 
and  the  patients  show  paralytic  phenomena  or  melancholia 
with  stupor  or  Jacksonian  epilepsy.  Edema  of  the  brain 
and  hemorrhagic  foci  were  found  on  trephining,  and  lumbar 
puncture  gave  great  relief. 


Baumel,  J.:  Lumbar  Puncture  in  Nervous  Shock  and  Wounds  of 
the  Skull  in  War  (La  ponctiou  lombaire  clans  les  commotions 
nervveiises  et  les  traumatismes  clu  crane  par  projectiles  tie 
guerre).    Lyon  chir.,  1915,  xii,  271. 

Baumel  has  had  occasion  to  examine  the  cerebrospinal 
fluid  in  a  large  number  of  cases  during  the  war,  and  he  gives 
a  table  showing  in  detail  the  results  in  56  cases.  The  con- 
dition of  the  spinal  fluid  gives  important  information  as  to 
the  extent  and  severity  of  the  injury.  It  is  also  of  consid- 
erable value  in  treatment,  for  he  finds  that  the  pressure  of 
the  spinal  fluid  is  above  normal,  even  in  cases  of  mere  con- 
cussion where  the  projectiles  have  not  come  into  direct  con- 
tact with  the  skull.  Nearly  all  the  wounds  reported  were 
from  fragments  of  shells. 

If  the  spinal  fluid  shows  an  increase  in  the  polynuclear 
count  it  means  a  more  serious  prognosis,  for  polynucleosis  is 
an  index  of  infection.  When  there  is  only  Ij^mphocytosis 
The  meningitis  is  subacute.  Lumhar  -puncture  is  the  only 
rational  form,  of  treatment  in  simple  clisturhance  of  the  ner- 
vous system  and  in  nonpenetrating  loouncls  of  the  shull.  It 
is  valuable  also  in  cases  of  severe  injury  of  the  skull,  as  it 
reduces  the  symptoms  caused  by  high  pressure,  rids  the  sys- 
tem of  toxins,  and  hastens  recovery.  It  should  be  performed 
systematically  day  after  day  as  long  as  it  is  doing  good,  for 
it  is  absolutely  harmless. 


GERMAN  SCHOOL. 

A  survey  of  the  literature  so  far  has  shown  that  the  English 
school  is  predominatingly  conservative  in  setting  their  indications 
for  operative  interference,  and  also  in  limiting  the  extent  of  opera- 
tive manipulations.     The  French  are  predominatingly  radical  along 


FOREIGN    WAR    LITERATURE.  173 

these  two  lines.  As  will  be  seen  in  the  following  abstracts,  the 
German  school  seems  to  be  still  in  process  of  orienting  itself.  Arti- 
cles by  various  men,  following  each  other  in  close  succession,  furnish 
diametrically  contrary  advice.  For  example,  the  following  abstract 
of  Allers's  paper  seems  to  point  most  unequivocally  against  early 
operation  in  brain  cases,  and  calls  particular  attention  to  the  very 
important  question  of  the  influence  of  transport  on  patients  with 
cranial  injuries. 

Allers:  Transport   of   Wounded   With   Head   Injuries.      Wien.   Jclin. 
Wchnschr.,  1916,  Sept.  7. 

Allers  has  studied  the  important  question  whether  it  is 
best  to  immediately  operate  upon  cranial  wounds  at  the 
advanced  formations  or  to  send  them  unoperated  to  the  base 
hospitals.  Sixty-six  of  these  cases  were  operated  upon  at 
the  front  and  then  sent  to  the  base. 

Transportation  within  the  -first  five  days  after  operation 
means  certain  death,-  while  the  percentage  of  deaths  falls 
gradually  to  nothing  if  transportation  is  delayed  for  four  to 
-five  weeks. 

Experience  has  shown  that  operation  in  cranial  wounds 
deferred  even  up  to  three  or  four  days  after  injury  still  gives 
good  results.  Allers  finds  that  operations  executed  within 
the  first  week  give  a  mortality  of  12  per  cent.  It  therefore 
seems  best  not  to  operate  at  the  front;  but  if  this  is  done 
then  an  interval  of  at  least  10  to  12  days  should  elapse 
before  the  man  is  sent  to  the  rear. 

Allers  thinks  that  the  reason  why  the  unoperated  stand 
transportation  better  than  the  operated  is  to  be  found  in  the 
behavior  of  recent  wounds.  In  such  there  is  a  very  rapid 
formation  of  adhesions  of  the  dura  in  the  periphery  of  the 
injury.  There  is  a  concomitant  increase  of  verebral  tissue 
as  well  as  an  increase  of  pressure,  all  of  which  tend  to  pre- 
vent diffusion  of  infection.  But  if  fragments  of  bone,  etc., 
are  removed  secretory  flow  and  tension  are  diminished,  and 
there  is  little  obstacle  to  the  spread  of  infection.  Autopsy 
findings  confirm  this  point  of  view. 


The  stand  taken  by  Allers  is  supported  by  no  less  an  authority 
than  Tilmann,  whose  paper  is  valuable  and  meaty  in  that  it  dis- 
cusses the  value  of  mortality  statistics,  hemorrhage,  inflammation, 
removal  of  foreign  bodies,  infectivity  of  the  brain,  and  the  per- 
formance of  plastic  operations.  Likewise  Friedrich  supports  the 
conservative  stand,  even  going  so  far  as  to  state  that  frank  symptoms 
of  compression  do  not  demand  immediately  operation.  Friedrich 
advises  local  anesthesia  in  all  early  operations. 

Let  it  he  very  clearly  understood  that  when  these  various  op- 
erators argue  against  early  operation  their  purpose  is  not  always  to 


174  WAR   SUEGEEY   OF    THE    NERVOUS   SYSTEM. 

deny  patients  adequate,  intelligent,  and  careful  operative  first  aid,  hut 
merely  to  point  out  the  necessity  of  doing  as  little  work  on  the  skull 
as  possible,  and  in  no  loay  to  tamper  with  the  train,  before  transport 
of  the  patient  to  a  hase  hospital. 

Tilmann  and  Enderlen:   Gunshot  Wounds  of  the   Skull    (Scliildel- 
schiisse).    Beitr.  z.  kiln.  Cliir.,  1915,  xcvi,  454. 

Tilmann  and  Enderlen  read  papers  on  this  subject  before 
the  meeting-  of  military  surgeons  recently  held  in  Brussels. 
They  are  in  accord  as  to  most  points,  though  Tilmann  recom- 
mends at  first  only  the  necessary  care  of  the  wound,  while 
Enderlen  is  an  advocate  of  early  operation.  Percentages  in 
regard  to  mortality  are  of  no  special  value  in  these  injuries, 
for  many  die  later,  after  apparent  recovery. 

There  is  little  danger  of  hemorrhage,  for  skull  wounds 
bleed  little.  The  greatest  danger  is  that  of  infection,  causing 
meningitis  or  encephalitis.  There  may  be  a  nonseptic  en- 
cephalitis from  the  inflammatory  reaction  of  the  brain  to 
the  presence  of  the  foreign  body,  even  though  it  is  not  in- 
fected. It  therefore  becomes  a  question  whether  there  is 
greater  danger  in  removing  the  projectile  or  leaving  it. 
Operation  should  be  performed  only  when  aseptic  treatment 
of  the  wound  can  be  guaranteed. 

The  brain  is  very  sensitive  to  infection  and  also  to  the 
action  of  disinfectants,  so  that  their  use  in  operations  does 
more  harm  than  good.  Projectiles  remaining  in  the  brain 
should  not  be  removed  until  their  exact  location  has  been 
determined  by  means  of  X-ray.  In  any  necessary  probing 
of  the  brain  the  finger  should  be  used,  rather  than  an  instru- 
ment, for  the  finger  can  detect  the  difference  in  consistency 
between  blood-clot  and  brain  substance,  while  a  sound  can 
not.  Operation  on  the  brain,  when  necessary,  can  be  per- 
formed without  an  anesthetic  at  all  or  under  local  anesthesia. 

Meningitis  should  be  treated  by  repeated  lumbar  puncture. 
Encephalitis  is  much  more  frequent  than  meningitis;  the 
suppurative  form  is  rapidly  fatal.  The  serous,  hemorrhagic, 
and  reactive  forms  may  recover.  If  the  disease  becomes 
chronic  brain  abscesses  are  formed,  which  have  to  be  emptied 
by  trephining.  The  nonsuppurative  form  of  encephalitis 
may  lead  to  softening  and  discharge  of  brain  substance,  or 
if  the  brain  substance  does  not  give  way  cysts  may  be 
formed;  these  may  arise  a  long  time  after  the  injury.  No 
patient  who  has  had  a  brain  injury  should  be  transported 
for  at  least  8  days,  even  if  there  is  apparent  recovery.  He 
should  remain  under  medical  surveillance  for  at  least  three 
weeks.  Plastic  operations  are  not  advisable  early,  and  even 
later  they  should  be  performed  only  when  there  are  strict 
indications.  Every  effort  should  be  made  to  secure  healing 
by  first  intention,  for  it  has  been  found  that  later  epileptic 
attacks  are.  much  more  frequent  in  cases  where  there  has 
been  a  prolonged  period  of  suppuration. 


FOKEIGN  WAR  LITERATURE.  175 

Friedrich,  P.  L,:  Operative  Indications  in  Gunshot  Injuries  of  the 
Brain  in  War  (Die  openifive  iDdikutionsstelluny  bei  den  Hini- 
schiisseii  im  Kriege).  Beitr.  z.  klin.  Vliir.,  1914,  xci,  271.  (By 
Zentrulbl.  f.  d.  ges.  Chir.  u.  i.  Grenzgeb.) 

There  is  a  large  percentage  of  gunshot  injuries  of  the 
brain  among  the  cases  of  death  and  of  wounds  handled  dur- 
ing war.  The  methods  in  civil  surgery,  which  are  not  uni- 
form by  any  means,  are  not  always  applicable  in  war.  Fried- 
rich  recommends  that  in  injuries  in  civil  life  the  wound  be 
cared  for  at  once,  but  only  in  exceptional  cases  should  there 
be  any  operative  procedure  on  the  brain ;  the  entrance  wound 
should  be  left  partly  open,  so  that  wound  secretion,  bits  of 
necrotic  brain,  and  foreign  bodies  may  be  discharged.  An 
illustration  is  given  of  Thiersch's  crown  bandage,  which 
leaves  the  wound  free.  From  statistics  of  previous  wars 
no  general  rules  can  be  laid  down  as  to  war  surgery,  as 
the  varying  conditions  must  be  taken  into  consideration. 
In  war  it  is  not  a  question  of  trephining  but  of  operation  on 
an  already  open  skull.  There  are  various  kinds  of  injuries 
to  the  brain,  and  simple  nomenclature  should  be  agreed  upon 
for  the  purpose  of  general  understanding.  As  to  depth, 
rebounding  and  grazing  shots  are  distinguished;  also  open 
shots,  either  penetrating  the  whole  skull,  or  making  a  uni- 
lateral wound;  another  classification  is  into  wounds  of  the 
base  or  other  regions  of  the  skull. 

In  war  a  skilled  surgeon  should  immediately  look  after  the 
wound,  but  the  skull  should  be  spared  as  much  as  possible. 
Not  all  fragments  need  be  removed,  but  only  those  lying  free 
in  the  wounded  area  or  those  pressing  against  the  brain. 
The  degree  of  operation  on  the  skull  is  illustrated  by  ex- 
periences in  the  hospital  at  Saloniki,  where  it  was  observed 
that  too  active  operative  procedures  often  produced  bad  re- 
sults, while  the  results  of  expectant  treatment  were  good.  In 
closed  injuries  to  the  brain  expectant  treatment  is  still 
more  indicated — at  least  attention  to  the  extrance  and  exit 
wounds.  Injuries  to  the  base  do  not  belong  to  primary  sur- 
gery. Indications  in  rebounding  shots,  in  hemorrhage  in- 
side the  skull,  and  in  the  brain  are  discussed. 

Even  symptoms  of  brain  pressure  do  not  demand  imme- 
diate operation  if  they  are  not  progressive;  sometimes  even 
a  technically  correct  early  operation  does  not  prevent  late 
infection.  The  greatest  reserve  is  also  recommended  when 
there  are  signs  of  cortical  irritation  in  depressed  fractures. 
Contractures  are  more  of  an  indication  for  operation  than 
convulsions.  Disturbances  of  speech  may  appear  even  in  in- 
juries that  are  far  away  from  the  speech  center.  In  all  early 
operations  general  anesthesia  should  be  abandoned  in  favor 
of  local  anesthesia  in  connection  with  morphine  injections. 
When  and  where  primary  operations — that  is,  operations 
within  the  first  48  hours — shall  be  performed,  depends  on 
the  means  for  transportation  and  care  of  the  soldiers.  In- 
juries of  the  skull  and  brain  should  be  attended  to  as  soon  as 
possible  either  on  the  field  or  in  its  immediate  neighborhood. 


1'76  WAE   SURGERY  OP   THE   NERVOUS  SYSTEM. 

Among  the  late  cases  signs  of  brain  jDressure  without  in- 
fection are  unusual.  Infection  predominates  in  these  cases, 
and  are  to  be  judged  by  their  clinical  signs.  A  rise  in  tem- 
perature without  any  other  cause  serves  as  a  warning.  Op- 
erative interference  should  be  undertaken  through  one  of 
the  wound  openings.     Several  case  histories  are  given. 


Frey  and  Selye,  Wilms,  and  Hosemann  take  a  very  radical  stand, 
practically  recommending  early  operation  in  all  cases,  stating  their 
reasons  and  furnishing  data  on  brain  involvement,  technique,  drain- 
age, foreign  bodies,  etc.  Frey  takes  definite  issue  with  those  surgeons 
who  claim  that  transport  has  any  deleterious  effects.  Mueller's  work 
is  interesting  chiefly  from  the  point  of  view  of  statistics.  He  was 
stationed  at  a  base  hospital,  and  therefore  not  confronted  with  the 
problems  of  when  and  to  wdiat  extent  it  was  necessary  to  interfere. 

Frey,  H.,  and  Selye,  H.:  Surgery  of  Gunshot  Injuries  of  the  Brain 

(Beitraae  zur   Chirurgie   der   Schuss\eiietzungen   cles   Gehirns). 
Wien.  Mill.  Wclmschr.,  1915,  xxviii,  693,  723. 

All  cases  of  gunshot  injury  of  the  brain  should  be  carried 
from  the  front  to  where  they  can  get  hospital  treatment  as 
quickly  as  possible,  so  that  they  may  be  operated  upon  at 
once.  There  is  no  particular  danger  of  injury  from  the 
transportation.  On  the  field  a  simple  occlusion  dressing  is 
all  that  is  necessary,  and  this  should  not  be  changed  until 
the  patient  has  arrived  at  the  hospital.  No  definite  con- 
clusions as  to  the  extent  and  depth  of  the  injury  can  be 
drawn  from  the  external  appearance. 

All  wounds  should  be  carefully  incised  and  explored.  If 
the  bone  is  found  intact,  no  further  operation  is  necessary ; 
but  if  the  bone  is  injured  the  skull  must  be  opened  up. 
Enough  bone  must  be  removed  so  that  sound  and  normal 
dura  can  be  seen  in  all  directions.  After  the  removal  of 
foreign  bodies,  splinters  of  bone,  and  crushed  brain  tissue, 
a  cross-shaped  incision  is  made  in  the  dura,  reaching  to  the 
edges  of  the  bone.  The  wound  must  be  dressed  in  such  a 
way  that  the  exposed  parts  of  the  brain  are  not  pressed 
upon  either  by  the  dressings  or  by  the  natural  coverings  of 
the  brain.  Prolapse  of  the  brain  appearing  later  is  of  no 
significance  if  pulsation  in  it  continues.  If  pulsation  ceases 
the  prolapse  should  be  reduced  and  the  brain  explored  again. 

After  serious  brain  operations  the  authors  give  urotropine, 
2  to  ?)  gms.  per  day,  internally,  on  account  of  its  effect  on 
the  cerebrospinal  fluid.  When  treated  in  this  way  the 
prognosis  is  very  good.  Only  8  per  cent  of  the  authors' 
cases  died,  but  the  time  since  operation  is  too  short  to  report 
on  permanent  results. 


FOREIGN    WAR    LITERATURE.  177 

Wilms:  Treatment  of  Tangential  Wounds  of  the  Skull  (Uiclitlinieu 
in  der  BehaiuUung  der  ScliaedeltaiifientialscliiH'sse).  Muenchen. 
med.  Wchnschr.,  1915,  Ixii,  1437. 

Tangential  gunshot  wounds  of  the  skull  demand  early  and 
thorough  operation;  fragments  of  bone  should  be  removed 
and  crushed,  and  softened  parts  of  the  brain  carefully 
washed  out  with  salt  solution.  Gauze  strips  wet  with  bal- 
sam of  Peru  should  then  be  laid  on  the  exposed  brain  to 
prevent  infection.  The  treatment  is  very  effective,  as  shown 
by  the  author's  four  years'  experience  with  it.  If  operation 
is  performed  at  once  there  is  only  the  local  injury  of  the  brain 
to  deal  with ;  there  is  no  increased  intracranial  pressure,  but 
by  the  second  day  there  is  a  diffuse  oedema,  which,  even  if  it 
is  not  infected,  tends  to  produce  a  prolapse.  If  operation  is 
delayed  this  long  a  larger  opening  has  to  be  made  in  order 
to  provide  for  the  discharge  of  the  exudate,  and  it  is  more 
difficult  to  wash  out  the  softened  parts  of  the  brain,  for  it  is 
hard  to  distinguish  them  from  the  surrounding  cedematous 
brain  tissue.  Of  course  the  situation  will  be  still  more  com- 
plicated if  the  exudate  is  inflammatory  in  nature.  Wilms's 
work  has  been  in  a  home  hospital  and  he  has  had  frequent 
occasion  to  see  the  bad  late  results  of  cases  that  were  not 
promptly  operated  upon. 

Puncture  should  not  be  performed  for  the  sake  of  locat- 
ing a  brain  abscess.  New  infection  is  introduced  by  the 
puncture  needle  as  often  as  the  abscess  is  located.  Abscesses 
must  be  located  by  free  incision,  and  this  is  especially  true 
of  the  abscesses  from  tangential  injuries,  which  generally  lie 
very  near  the  surface.  In  case  of  prolapse,  which  indicates 
increased  intracranial  pressure,  extensive  trephining  must 
be  performed.  Wilms  does  not  believe  that  gaps  in  the  skull 
should  be  closed  by  plastic  operation,  at  least  not  until  a 
year  or  more  after  the  injury,  for  the  patient  is  for  many 
months  subject  to  the  danger  of  late  effects  from  the  wound, 
and  it  should  not  be  closed  up  by  plastic  operation. 


Hosemann:  Early  Surgical  Treatment  of  Gunshot  Wounds  of  the 
Skull  (Die  chii-urgisclie  Friilibeliandluiig  der  Schiidelscliiisse). 
Deutsche  med.  ^Ychnschr.,  1915,  xli,  607. 

Hosemann  had  charge  of  a  dressing  station  north  of  the 
Aisne  for  eight  w^eeks.  Injuries  of  the  skull  were  extra- 
ordinarily frequent.  He  had  79  cases,  and  as  there  was 
time  to  give  considerable  care  to  each  case  they  w^ere  treated 
at  the  dressing  station  rather  than  forwarding  them  to  the 
ho.spitals.  This  is  preferable  if  the  conditions  permit  of  it 
at  all,  for  transportation  is  particularly  dangerous  in  these 
cases.  The  hair  was  cut  away,  the  Avounds  painted  with 
tincture  of  iodine;  and  if  necessary  to  get  a  clear  view  of 
the  skull,  the  scalp  wound  was  enlarged.  In  24  cases  this 
procedure  showed  that  operation  was  necessary.  Nine  of 
these  patients  died. 

137f;4— 17 12 


178 


WAR    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 


There  was  very  little  infection  among  the  cases — one  case 
of  meningitis  and  one  of  superficial  brain  abscess.  The 
hrain  is  not  so  sensitive  to  infection  as  is  commonly  believed 
if  it  is  given  the  necessary  care  early.  Another  important 
point  is  to  provide  free  drainage  in  order  to  avoid  pressure 
on  the  brain.  Dressings  should  be  changed  often  so  that  the 
wound  secretion  may  be  discharged.  Discharge  of  brain 
substance  is  not  in  itself  especially  dangerous ;  it  is,  however, 
an  evidence  of  increased  intracranial  pressure,  and  indicates 
an  examination  for  hematoma  or  brain  abcess.  The  advice 
of  some  authors  to  close  all  defects  in  the  skull  by  flaps  of 
periosteum  fascia,  etc.,  is  therefore  based  on  a  mistaken  con- 
ception. It  increases  the  very  condition  that  is  causing  the 
brain  prolapse.  The  indication  in  such  cases  is  to  keep  the 
wound  open,  not  to  close  it. 


Mueller,  F.:  The  Operative  Treatment  of  Cranial  Gunshot  Injuries 

(Zur  operativen  Behandlung  der  Scliaeclelschiisse).    Beitr.  .c.  Jxlin. 
Chir.,  1916,  c,  Krieyschir.  Heft.,  73. 

In  the  last  11  months  since  Mueller  took  charge  of  the 
surgical  division  of  the  Tilsit  Hospital,  he  has  treated  180 
gunshot  injuries  of  the  skull,  among  which  were  11  through 
shots,  20  retention  shots,  and  116  ricochet  and  tangential 
shots. 

There  is  no  doubt  as  to  the  seriousness  of  the  injury  in 
segmental  and  diametrical  gunshot  injuries,  where  the  brain 
is  usually  involved,  but  in  tangential  and  retention  gunshots 
it  is  only  in  a  portion  of  the  cases  that  serious  symptoms  are 
evident  on  inspection,  and  even  the  Roentgen  examination 
is  often  not  reliable.  Such  injuries  may  for  a  long  time  give 
no  indication  of  dangerous  injuries  to  the  skull  and  brain. 
To  await  such  symptoms  leaves  the  patient  in  constant  clan- 
ger of  his  life,  the  attendants  in  continual  worry,  and  the 
responsible  surgeon  cause  to  reproach  himself  later. 

From  these  considerations  Mueller  decided  to  expose  every 
cranial  injury,  even  those  appearing  harmless.  As  a  rule 
the  situation  becomes  clear  with  one  incision.  He  is  fully 
convinced  that  a  great  part  of  his  success  is  due  to  such 
primary  intervention.  The  distribution  of  the  180  cranial 
injuries  is  shown  in  the  table  below : 


Situation  of  cranial  injury. 


Soft-part  giuishots . . . 
Extradural  gunshots 
Intradural  gunshots . 
Brain  gunshots 


Total 

Deaths 

Mortal- 

Recov- 

due to 

ity  (per 

ered 

injury. 

cent). 

cases. 

46 

0 

0 

46 

22 

0 

0 

22 

38 

1 

2.63 

37 

174 

29 

39.19 

45 

Recov- 
ery (per 
cent). 


100 

100 
97.37 
60.81 


1  Of  these,  41  were  primarily  operated;  14  died,  66  per  cent  recovered;  33  were  secondarily 
operated;  15  died. 


FOREIGN  WAR  LITERATURE.  179 

Of  the  180  skull  injuries  132  were  treated  by  eurly  opera- 
tion. Of  these  00.5  per  cent  were  operated  upon  within  the 
first  week  of  the  injury,  29  per  cent  in  the  second  week,  and 
the  remainder  in  the  third  w-eek  and  later.  Of  the  180  cases 
31  died,  30  from  the  direct  results  of  the  injury.  Four  pa- 
tients died  later  in  their  home  hospitals.  Most  of  these 
deaths  were  caused  by  brain  complications  Avhich  Avere  clini- 
cally of  tw'o  distinct  types.  In  the  first  the  symptoms  were  of 
a  fulminating  character  accompanied  by  high  temperature 
and  resulting  in  early  death.  The  parts  of  the  brain  soft- 
ened by  the  wound  oozed  continuously,  indicating  strong 
intracranial  tension.  It  was  not  demonstrated  whether  or 
not  there  was  a  bacillar  activity,  but  such  assumption  is 
plausible.  In  the  second  type  the  symptoms  were  insidious, 
the  destructive  process  extending  gradually  until  it  reached 
a  ventricle,  when  rupture  occurred,  followed  by  a  suppura- 
tive ventricular  inflammation  and  a  bacillar  meningitis. 

From  the  percentages  of  mortality  and  recovery,  the  final 
success  of  the  operative  treatment  can  be  established.  First 
there  is  the  noticeable  result  that  of  all  extradural  injuries 
there  is  an  operative  recovery  of  97  per  cent. 

Of  the  gunshot  injuries  involving  the  brain  61  per  cent 
recovered.  Mueller's  statistics  show  that  after  primary  op- 
eration alone  66  per  cent  finally  recovered.  In  those  cases 
where  a  secondarj'^  operation  was  later  necessitated  there 
was  only  33  per  cent  of  ultimate  recoveries.  As  against  the 
33  per  cent  recovered  after  secondary  operation,  the  primary 
operated  cases  give  a  total  recovery  of  66  per  cent.  This 
comparison  shows  the  importance  of  primary  operation. 
Mueller  thinks  that  in  reference  to  gunshot  skull  injuries, 
success  or  nonsuccess  depends  upon  the  favorable  issue  of  the 
first  operative  treatment.  Retention  gunshot  wounds  have 
a  high  mortality  of  70  per  cent,  showing  how  destructive 
are  the  effects  of  a  projectile  remaining  in  the  brain. 

In  primary  operated  tangential  shots  the  mortality  is  22.73 
per  cent,  which  gives  the  pleasing  result  that  of  100  tan- 
gential shot  injuries,  77  recovered  owing  to  primary  opera- 
tion. 


The  article  by  Brandes  is  interesting  from  the  fact  that  his  data 
are  based  not  only  on  the  present  conflict  but  also  on  the  last  Balkan 
war;  and,  furthermore,  in  that  his  stand  furnishes  a  possible  basis 
for  interpreting  the  divergency  of  view  of  the  radicals  and  con- 
servatives. His  dictum  is:  Base  time  and  type  of  interference  on 
type  of  missile. 

Brandes:  Treatment  of  Cranial  Wounds.  Deutsche  Med.  Wchnschr., 
1916,  No.  23. 

Brandes  notes  that  the  numerous  publications  on  gunshot 
cranial  wounds  show  a  great  diversity  of  opinion  as  regards 
treatment,  especially  as  to  wounds  with  arrested  projectiles. 

Many  surgeons  proceed  only  on  the  basis  of  their  personal 


180  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

observations,  which  are  few.  Some  have  abandoned  con- 
servative treatment  and  undertake  operations  varying  from 
simple  and  superficial  interventions  to  radical  measures; 
others  limit  their  operations  to  selected  cases. 

Brancles's  experiences  in  the  last  Balkan  War  and  in  the 
present  war  have  led  him  to  proceed  approximately  accord- 
ing to  the  ideas  of  Holbeck  and  of  Oettinger,  i.  e.,  conserva- 
tive treatment  at  first  in  wounds  hy  arms  of  small  caliber^ 
and  radical  intervention  in  the  case  of  shrapnel  uwunds,  and 
to  abandon  this  rule  only  in  certain  select  cases.  His  con- 
clusions are  summarized : 

1.  In  the  indications  for  operative  intervention  in  gunshot 
wounds  with  projectile  arrested  in  the  brain  (not  in  the 
cranium)  w^e  must  clearly  distinguish  between  projectiles 
of  small  caliber  and  those  of  artillery. 

2.  In  case  of  brain  lesions  from  small-caliber  projectiles 
operation  is  performed  only  when  there  is  evidence  of  begin- 
ning infection  or  progressive  manifestations  of  cerebral 
compression,  which  call  for  intervention.  Otherwise  con- 
servative treatment  proceeds  as  advised. 

(3)  In  shrapnel  or  grenade  wounds  with  arrest  of  the 
projectile  in  the  brain  the  author  intervenes  at  once  unless 
there  is  small  probability  of  being  able  to  immediately  re- 
move the  projectile.  He  can  not  confirm  either  by  his  own 
observations  or  from  autopsies.  Holbeck's  idea  that  in 
shrapnel  injuries  with  the  projectile  arrested  in  the  brain  the 
projectiles  exhaust  their  force  in  traversing  the  skull  cap- 
ping, since  the  bullet  is  often  found  at  a  depth  of  2  to  3  cm. 
in  the  brain. 

(4)  Bier's  method  of  causing  the  bullet  to  fall  by  blows 
against  the  head  did  not  succeed  in  three  cases  in  which  the 
author  tried  it. 

(5)  Various  theoretical  considerations  also  militate 
against  the  probability  of  this  method  succeeding;  besides 
it  can  not  be  considered  harmless ;  it  is  less  dangerous  to  in- 
tervene wdth  the  gloved  finger  to  reach  the  bullet  and  then 
extract  it. 

6.  If  the  bullet  is  not  found  at  a  reasonable  depth  in  the 
brain,  the  author  limits  himself  to  tamponing  the  brain 
cavity  and  keeping  the  external  aperture  open  in  case  of  an 
initial  encephalitis.  Symptomatic  prolapse  invites  inter- 
vention with  good  prospects;  the  encephalitis  should  be 
treated  and  the  prolapsed  pedicles  freed  by  a  wider  removal 
of  bone.  The  removal  of  the  projectile  can  be  obtained  sec- 
ondarily. 

The  work  of  Barany,  Jeger,  Manasse,  Marburg  and  Ranzi,  and 
Bruns  deals  almost  exclusively  with  the  topic  of  infectivity  of  the 
brain  and  the  development  of  traumatic  brain  abscess.  Barany's 
work  is  important  as  coming  from  a  master  in  this  particular  field. 
What  he  says  about  closing  brain  wounds  without  drainage  is  there- 
fore entitled  to  careful  consideration,  even  though  his  views  conflict 
with  those  of  many  of  his  German,  French,  and  English  colleagues. 


FOREIGN    WAR    LITERAITJRE.  181 

Manasse  recommends  the  gauze  tampon,  the  use  of  which  Cashing 
so  unqualifiedly  condemned  in  the  treatment  of  brain  injuries.  Both 
Manasse  and  Marburg  and  Ranzi  furnish  details  on  the  symptom- 
atology of  brain  access.  Bruns's  article  is  included  at  this  point,  in 
spite  of  the  fact  that  it  deals  largely  with  cord  and  nerves,  for  the 
reason  that  it  also  deals  with  the  symptomatology  and  treatment  of 
brain  abscess. 

The  subject  of  brain  abscess  does  not  seem  to  be  treated  as  ade- 
quately in  the  war  literature  as  it  is  in  the  larger  hand  and  text  books 
of  neurology  and  surgery. 

Barany,  R.:  Open  and  Closed  Treatment  of  Gunshot  Wounds  of  the 
Brain  (Die  offene  uiul  geschlossene  Behandlung  der  Schussver- 
letZungen  des  Gehirns).    Beitr.  z.  klin.  Chir.,  1915,  xcvii,  397. 

Barany  treated  60  cases  of  gunshot  injury  of  the  brain  at 
a  hospital  in  Przemysl,  where  he  had  an  opportunity  to  ob- 
serve them  throughout  the  course  of  the  injury.  In  all  cases 
he  cut  away  the  bone  until  0.5  cm.  of  the  dura  was  exposed, 
and  then  carefully  removed  fragments  of  bone  and  foreign 
bodies.  In  the  first  39  cases  he  left  the  wounds  open,  drain- 
ing with  gutta-percha  strips,  which  he  found  to  be  the  best 
for  the  purpose.  He  had  8  recoveries  and  31  deaths,  or  20.5 
per  cent  recoveries.  However,  6  of  the  cases  were  in  almost 
a  dying  condition  when  admitted,  and  subtracting  these  it 
gives  23.6  per  cent  recoveries. 

After  having  seen  some  cases  in  which  bullets  had  passed 
entirely  through  the  brain  and  in  which  the  patients  had 
recovered  without  infection,  it  occurred  to  Barany  that  bul- 
let wounds  of  the  brain  might  not  necessarily  be  infected 
primarily,  and  if  they  are  noninfected  closed  treatment  is 
indicated  to  prevent  secondary  infection.  In  accordance 
with  this  idea  he  operated  on  21  cases  as  before  and  sutured 
the  wounds  at  once  in  14  of  the  cases ;  the  other  7  cases  were 
complicated  by  injuries  of  the  eye  and  nasal  sinuses.  Of  the 
14  cases  4  died,  but  they  were  in  a  hopeless  condition  when 
admitted.  The  other  10  recovered,  and  in  7  of  these  cases  the 
wounds  were  so  severe  that  he  believes  they  would  not  have 
recovered  under  open  treatment.  He  thinks  the  majority 
of  cases  that  can  be  treated  within  24  hours  after  the  injury 
are  not  infected,  and  that  the  wounds  should  be  sutured, 
thus  preventing  secondary  infection.  Of  course  if  they  are 
already  so  severely  infected  that  abscess  has  developed  they 
should  be  left  open  and  drained. 


Barany:  Primary  Suture  of  Gunshot  Wounds,  Especially  of  the 
Brain  (Primare  Wundnaht  bei  Schussverletzungen,  Speziell  des 
Gehirns).     Wicn.  klin.  Wchnschr.,  191.5,  xxviii,  525. 

Barany  describes  a  number  of  cases  of  gunshot  injury  of 
the  brain  from  which  he  draws  the  conclusion  that  it  is 
better  to  suture  at  once  without  drainage.     Theoretically 


182  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

these  wounds  are  to  be  regarded  as  infected,  but  practically 
they  may  be  regarded  as  sterile  and  sutured.  He  believes, 
moreover,  that  in  gunshot  wounds  in  general  much  better 
results  would  be  obtained  if  wounds  were  cleansed,  the  skin 
excised  if  necessary  and  sutured  at  once  at  the  dressing  sta- 
tion, than  by  the  present  method  of  simply  dressing  them 
and  sending  them  on  to  the  hospital.  He  thinks  the 
w^ounded  men  would  recover  much  sooner  and  be  ready  for 
military  service  again.  Of  course  it  would  be  necessary  to 
simplify  the  procedure  as  much  as  possible.  Instruments 
could  be  kept  in  alcohol  all  the  time  and  the  surgeon's  hands 
sterilized  with  alcohol  if  water  and  soap  were  not  obtainable. 
Excision  of  skin  wounds  could  generally  be  accomplished 
under  local  anesthesia  or  without  anesthesia  at  all.  Prac- 
tice would  enable  the  surgeon  to  suture  most  wounds  in  a 
few  minutes. 

The  objection  is  made  that  the  patients  would  have  to  be 
transported  and  could  not  be  under  medical  observation,  but 
Barany  holds  that  they  would  not  be  any  worse  off  than  they 
are  with  their  wounds  simply  bandaged.  There  would  be 
even  less  danger  of  hemorrhage  and  infection,  for  the  patient 
is  exposed  to  both  these  dangers  by  displacement  of  the 
dressings  during  transportation.  If  ithe  principle  were  once 
established  that  gunshot  wounds  should  be  sutured  immedi- 
ately, means  could  readily  be  found  for  carrying  it  out. 


Jeger,  E.:  Plastic  Closure  of  the  Dura  with  Fascia  in  Gunshot 
Wounds  of  the  Brain  (Ueber  primaere  Fascienplastik  bei 
Schussverletzungen  der  Dura).  Beitr.  z.  klin.  Cliir.,  1915,  xcvii, 
418. 

Jeger  was  a  coworker  with  Barany  in  his  w^ork  on  gunshot 
injuries  of  the  brain,  and  agrees  fully  with  the  latter's  con- 
clusions in  regard  to  the  superiority  of  closed  treatment  in 
such  wounds.  He  thinks  the  good  results  may  be  due  to  the 
fact  that  the  brain  is  placed  under  better  physiological  con- 
ditions when  the  wound  is  closed,  and  so  is  better  able  to 
resist  any  infection  that  may  have  taken  place.  As  a  fur- 
ther step  in  the  closure  of  such  wounds  he  replaced  the  defect 
in  the  dura  with  fascia  in  three  cases,  the  details  of  which 
are  given.  The  fascia  prevents  adhesions  between  the  brain 
and  skull,  and  the  later  results  of  such  adhesions,  as  fistula 
and  brain  prolapse.  Moreover,  the  physiological  conditions 
are  more  completely  restored  when  the  brain  is  enveloped 
in  all  its  coverings,  and  the  fascia  offers  a  still  further  pro- 
tection against  infection  from  outside.  It  also  makes  it 
possible  to  perform  a  secondary  operation  to  repair  the 
skull  without  exposing  the  brain.  The  fascia  also  has  a 
hemostatic  action  that  furthers  recovery. 

Jeger  has  thus  far  performed  the  above  operation  only 
in  cases  where  there  was  such  a  large  defect  in  the  dura  that 
there  was  danger  of  prolapse.  The  fascia  is  simply  cut 
out  and  laid  with  its  inner  surface  next  the  brain  after  the 
wound  has  been   cleansed.     The   edges  of  the   fascia   are 


FOREIGN    WAR   LITERATURE,  183 

pushed  quite  a  distance  in  between  the  dura  and  bone. 
Sutures  are  not  necessary.  Considerable  fat  was  left  on  the 
fascia  and  this  helped  to  fill  in  the  gap  in  the  bone.  There 
was  healing  by  first  intention  in  all  the  cases.  He  believes ' 
that  primary  suture  in  brain  wounds  with  plastic  closure  of 
the  dura  brings  about  quicker  and  more  faA^orable  results 
than  open  treatement. 

He  also  suggests  as  an  operative  possibility  in  inflamma- 
tory hydrocephalus  externus  a  combination  of  a  plastic  op- 
eration on  the  dura,  with  the  suturing  of  a  piece  of  vein,  one 
end  under  the  fascia  and  the  other  in  the  external  jugular, 
so  as  to  drain  off  the  fluid  into  the  vein.  He  performecl 
this  operation  in  one  case,  but  the  patient  was  in  too  serious 
a  condition  to  be  saved. 


Manasse,  P.:  Treatment  of  Brain  Abscess  (Ziu-  Tlierjipie  des  Hiiu- 
iibszesses).     Mi'iiichcn.   med.    Wchnschr.,   1915,  Ixii,   1475. 

Much  can  be  done  to  prevent  brain  abscess  by  careful 
treatment  of  all  head  wounds.  They  should  be  opened  up 
thoroughly  and  examined  and  any  foreign  bodies  removed. 
The  wound  should  then  be  filled  with  loose  gauze  and  left 
open.  Skull  wounds  should  never  be  sutured,  as"\here  are 
almost  certain  to  be  late  complications  if  they  are.  Subdural 
hematomata  should  be  treated  conservatively ;  an  intact 
dura  should  not  be  opened  unless  there  are  urgent  symptoms. 
If  a  brain  abscess  forms  in  spite  of  these  precautions  it 
should  be  opened  up  freelj^  and  the  pus  drained  out,  care 
being  taken  to  reach  all  pockets  and  recesses.  Drainage 
should  be  provided  wdth  loose  gauze ;  never  with  rubber  or 
glass  tubes.  The  first  dressing  should  be  left  two  or  three 
days  and  after  that  the  wound  dressed  daily.  Each  time 
the  pus  should  be  carefully  but  thoroughly  sponged  out. 
The  patient  must  be  placed  in  the  best  position  for  free 
drainage.  He  must  be  watched  for  any  symptoms  of  re- 
tention of  pus,  such  as  fever,  vomiting,  headache,  or  locali- 
zing symptoms.  If  they  develop  the  cavity  must  be  pal- 
pated carefully  with  the  finger  to  discover  any  recesses. 

Sometimes  secondary  abscesses  form  in  a  prolapse;  if  so 
they  must  be  opened  up  and  if  necessary  the  prolapsed  part 
removed;  if  the  prolapse  shows  no  reaction  it  should  be 
treated  conservatively  until  it  can  be  restored.  If  a  fis- 
tula forms  into  the  ventricle  it  generally  results  in  basal 
meningitis  and  death.  The  abscess  cavity  granulates  very 
slowly  so  that  the  patients  have  to  remain  under  treatment 
for  months,  and  they  should  still  be  kept  under  observa- 
tion after  complete  healing,  for  they  are  very  subject  to 
later  diseases  of  the  brain.  For  this  reason  the  author  does 
not  believe  in  plastic  closure  of  gaps  in  the  skull.  He  has 
treated  11  patients  with  brain  abscess  in  a  military  hos- 
pital and  21  in  Strassburg.  Of  the  first  group  5  recovered 
and  6  died,  and  of  the  second  5  recovered,  4  died,  and  12  are 


184  WAR    SURGEEY    OF    THE    NERVOUS   SYSTEM. 

yet  under  treatment.  In  his  five  months'  work  in  Strass- 
burg  Manasse  had  265  cases  of  gunshot  wounds  of  the 
head,  in  which  21  cases  of  brain  abscess  developed., 


Marburg,  O.,  and  Ranzi,  E.:  Late  Abscess  After  Gunshot  Injury  of 
the    Brain     (Uber    Spatiibszesse    uncli    Scliussverletzungen    des 
Gehirns).     Nenrol.  Zentralhl.,  1915,  xxxiv,  54G. 

The  authors  have  operated  upon  62  cases  of  gunshot 
injury  of  the  brain  during  the  past  year,  with  23  deaths. 
Among  these  62  cases  abscess  was  found  at  operation  iu 
42.  But  there  were  a  number  of  patients  who  apparently 
recovered  perfectly  from  the  operation,  but  who  later  de- 
developed  abscesses  and  died.  Six  such  cases  are  described. 
The  abscesses  generally  developed  four  or  five  months  after 
the  operation ;  in  one  case  the  interval  was  eight  months. 

The  sj^mptomatology  of  late  abscess  is  quite  characteris- 
tw.  The  patient  shows  a  rise  of  temperature  for  awhile,  and 
then  suddenly  general  symptoms  develop,  such  as  headache, 
vomiting,  and  signs  of  beginning  meningitis.  There  is  apt 
to  be  an  increase  in  already  existing  local  symptoms,  such  as 
hemiplegia  or  aphasia.  These  phenomena  are  explained 
by  the  fact  that  the  abscess  has  been  strictly  encapsulated 
for  some  time,  but  finally  there  has  been  propagation  of  the 
pus  to  the  meninges  through  a  small  opening  into  one  of 
tlie  ventricles.  Often  when  the  abscess  becomes  manifest  it 
is  too  late  to  save  the  patient  by  operation,  but  cases  can 
often  be  saved  by  early  operation.  An  illustrative  case  is 
described. 

From  the  foregoing  it  is  evident  that  all  cases  of  brain  or 
skull  Avounds  should  be  kept  under  careful  observation  for 
several  months,  and  if  there  is  a  rise  of  temperature  or  the 
slightest  sign  of  cerebral  irritation  the  wound  should  be 
opened  up.  If  there  is  pus,  free  incision  and  drainage  are 
indicated. 


Bruns,  L.:  Indications  for  Surgery  in  War  Injuries  of  the  Nervous 
System,  and  the  Prognosis  of  These  Injuries  in  Themselves 
and  After  Operation  (Uber  die  Indikationeu  zu  den  therapeu- 
tisclien,  speziell  den  cliirurgischeii  Maasnahmen  bei  den  Kreig 
verletzungen  des  Nervensystems  und  iiber  die  Prognose  dieser 
A^erletsungen  an  sich  und  njicli  den  verschiedenen  Eingriffen). 
Berl.  kiln.  Wclmschr.,  1915,  lii,  989. 

Bruns  reports  his  experience  at  a  base  hospital  with 
376  cases  of  injury  of  the  peripheral  nerves,  89  of  the 
brain  and  skull,  and  37  of  the  spinal  column  and  cord. 

The  injuries  of  the  peripheral  nerves  he  divides  into 
three  groups:     (See  Chap.  Ill,  Peripheral  nerves.) 

(1)  In  the  first  group  the  function  of  the  whole  cross 
section  of  the  nerve  is  destroyed  at  the  site  of  the  lesion, 
so  that  all  the  muscles  supplied  by  it  are  paralyzed;  there 
is  complete  reaction  of  degeneration  in  the  paralyzed  mus- 
cles, and  sensation  in  the  region  supplied  by  the  nerve  is 
more  or  less  disturbed.  It  is  impossible  to  tell  whether 
the  nerve  is  completely  severed  or  whether  it  is  only  em- 


FOREIGN    WAR  LITERATURE.  185 

bedded  in  scar  tissue.  The  only  way  of  finding  out  is  to 
operate,  opening  up  to  the  nerve  and  then  proceeding  ac- 
cording to  the  findings.  Operation  should  be  performed 
as  soon  as  the  wound  is  healed,  any  accompanying  bone 
fractures  consolidated,  and  all  signs  of  sepsis  disappeared. 
If  during  this  period  of  waiting  there  has  been  marked 
improvement  in  the  symptoms,  operation  may  be  deferred, 
in  the  hope  of  spontaneous  restoration. 

(2)  In  the  second  group  of  cases  only  some  of  the  mus- 
cles supplied  by  the  nerve  are  paralyzed,  showing  that  the 
whole  cross  section  of  the  nerve  is  not  involved,  but  there 
is  complete  reaction  of  degeneration  in  the  muscles  that 
are  affected.  Operation  may  be  deferred  longer  in  these 
cases,  for  the  lesion  is  less  severe  and  they  are  more  apt 
to  recover  spontaneously. 

(3)  In 'the  third  group  the  reaction  of  degeneration  is 
only  partial.  These  cases  may  be  treated  by  electricity 
and  massage.  Neurolysis  is  especially  indicated  in  those 
cases  where  there  is  severe  and  long-continued  pain. 
Among  the  entire  number  of  injuries  of  the  peripheral 
nerves  that  Bruns  has  observed,  there  has  been  great  im- 
provement without  operation  in  33.  He  had  great  im- 
provement after  neurolysis  in  13  cases,  complete  recovery 
in  half  of  them.  He  has  had  successful  results  from  nerve 
suture  in  10  cases. 

The  lesions  of  the  spinal  cord  (see  Chapter  II,  Spinal 
Cord)  are  divided  into  those  in  which  the  whole  cross  section 
is  injured,  and  those  of  partial  injury.  In  the  cases  of  par- 
tial injury  operation  should  be  performed  only  if  the  roent- 
gen ray  shows  that  fragments  of  bone  or  projectiles  are  com- 
pressing the  cord,  or  if  septic  symptoms  demand  operation. 
In  the  majority  of  partial  injuries  operation  is  not  indicated, 
and  the  prognosis  without  it  is  much  better  than  might  be 
expected.  The  cases  of  total  injury  are  often  so  hopeless 
that  operation  is  useless.  There  are  cases,  however,  in  which 
operation  should  be  performed  if  the  patient's  condition 
permits  it,  though  with  or  without  operation  the  prognosis 
is  extremely  bad. 

The  skull  wounds  have  mostly  been  treated  before  they 
reach  the  base  hospital;  that  is,  the  wounds  have  been  ex- 
amined and  cleansed  and  fragments  of  bone  removed. 
These  cases  should  be  kept  under  observation  for  a  long  time 
at  the  base  hospital,  for  every  patient  with  a  brain  injury  is 
in  danger  for  a  long  period.  If  he  develops  signs  of  dizzi- 
ness, headache,  or  nausea,  his  temperature  should  be  taken 
and  the  eye-ground  examined.  If  high  tension  of  the  pulse 
or  mental  dullness  intervenes  the  wound  should  be  opened 
up  and  an  examination  made  for  brain  abscess.  If  bullets 
lodged  in  the  brain  are  superficial  they  should  be  removed, 
for  they  always  subject  the  patient  to  the  danger  of  late 
abscess.  If  they  are  deep  down  they  should  be  let  alone,  as 
tlie  danger  of  exploring  for  them  is  too  great;  but  it  is  often 
difficult,  even  with  good  roentgen  pictures,  to  tell  just  how 
deep  they  are.    The  author  has  operated  on  12  cases  of  brain 


186  WAE    SURGERY    OF    THE    NERVOUS    SYSTEM. 

abscess  with  four  deaths.  After  injuries  of  the  cortex,  at- 
tacks of  cortical  epilepsy  are  very  frequent.  He  lias  not  had 
sufficient  experience  to  say  whether  operation  is  indicated 
for  these.  The  prognosis  with  reference  to  mental  defect 
after  brain  injuries  is  quite  good.  Recovery  is  seldom  abso- 
lutely complete ;  for  instance,  after  an  aphasia  there  may  re- 
main slight  disturbances  in  reading  and  writing;  but  if 
important  association  tracts  are  not  involved  in  the  injur}^ 
the  patients  recover  sufficiently  to  lead  useful  and  active 
lives. 


The  work  of  Barth  on  meningitis  was  done  before  the  war,  but  we 
have  included  it  for  the  reason  that  it  was  Barth  who  stimulated  a 
renewal  of  interest  in  the  operative  cure  of  meningitis.  His  50  per 
cent  recover}^  list  is  startling  and  has  a  direct  bearing  on  the  menin- 
gitis cases  at  the  front.  It  must  be  added,  however,  that  Barth's  ex- 
cellent results  have  not  been  du]3licated  in  America. 

Barth:  Surgical  Treatment  of  Suppurative  Meningitis  (Ciiiiuigische 
Behandlung  tier  eitrigen  ileningitis).  Deutsche  Gesellsrli.  /. 
Chit:,  1914.     (By  Zentralbl.  f.  d.  ges.  Cliir.  u.  i.  Grenzgeb.) 

The  author  reports  three  cases  of  cerebrospinal  meningitis 
which  he  cured  by  laminectomy  of  the  lumbar  vertebrae  and 
drainage  of  the  sac  of  the  dura.  The  meningitis  had  devel- 
oped after  injuries.  Staphylococci,  diplococci,  and  strep- 
tococci were  found  in  the  fluid  obtained  on  lumbar  puncture. 
Before  the  operation  puncture  had  been  performed  several 
times  without  results. 

•  The  prospects  for  operative  cure  in  meningitis  are  not  so 
bad  as  is  commonly  assumed  if  operation  is  performed 
early  enough,  for  the  disease  begins  as  a  diffuse  process,  and 
encapsulation  of  the  pus  between  the  cerebral  convolutions 
does  not  take  place  until  later.  There  are  two  reasons  why 
there  has  been  such  great  skepticism  regarding  the  operation 
heretofore.  Recovery  was  thought  impossible,  because  only 
the  terminal  stages  of  the  disease  were  being  considered  and 
because  the  course  of  such  cases  after  operation  was  always 
thought  of.  It  should  not  be  forgotten  that  with  the  gradual 
development  of  meningitis,  leucocytosis  produces  a  stronger 
resistance  to  the  infection.  The  spinal  fluid  obtained  by 
lumbar  puncture  in  meningitis  has  a  markedly  bactericidal 
effect,  while  this  effect  is  completely  lacking  in  normal  cere- 
brospinal fluid. 

The  diagnosis  depends  on  the  presence  of  polynuclear 
leucocytes  in  the  fluid  from  lumbar  puncture ;  the  infecting 
bacteria  may  have  disappeared  under  the  influence  of  the 
leucocytes.  Recovery  has  been  brought  about  surgically 
thus  far  in  50  cases,'  most  of  them  in  otology.  Curability 
does  not  depend  to  any  great  extent  on  the  bacteriological 
findings;  cases  showing  pneumococci  and  streptococci  have 
been  cured. 

Lumbar  puncture  should  be  performed  on  the  very  frst 
appearance  of  symptoms  of  meningitis.     There  should  be 


FOKEIGN    WAR    LITERATURE.  187 

immediate  elimination  of  primaiy  foci  of  suppuration,  re- 
peated lumbar  puncture  to  relieve  brain  pressure,  and  if  this 
is  not  sufficient,  drainage  of  the  cavity  of  the  dura,  either 
through  the  lumbar  cord  or  the  skull.  Murphy  drains  in  the 
posterior  fossa  above  the  foramen  magnum  through  the 
cysterna  cerebellaris.  There  is  no  rational  ground  for  not 
treating  meningitis  operatively. 


It  has  been  practically  impossible  for  the  libraries  of  this  country 
to  secure  any  German  medical  literature  of  later  date  than  early 
1916.  Through  a  private  source  the  editors  were  fortunate  enough 
to  secure  the  1916  and  early  1917  numbers  of  the  important  German 
surgical  journals.  From  these  journals  we  have  abstracted  the  fol- 
lowing articles  by  Eiselsberg,  Erdelyi,  Axhausen,  Peres,  Guleke,  and 
Joseph  as  representative  of  the  latest  and  best  German  surgical 
thought.  It  is  patent  from  these  articles  that,  as  war  experience 
grows  in  Germany,  the  surgeons  are  veering  somewhat  more  toward 
a  conservative  stand  both  in  setting  their  indications  for  primary 
operative  interference  and  in  limiting  the  extent  of  their  primary 
surgical  procedures  in  treating  gunshot  injuries  of  the  head  imme- 
diately at  the  front. 

Von  Eiselsberg:  Report  on  Gunshot  Injuries  of  the  Brain  ((reliirn 
Schuesse  iusbesondere  Si>!it  Chirargie).  Report  at  the  Secoud 
German  Surgical  Congress.  Beitrdye  ziir  Klin.  Chir.  Bd.  Y, 
Eft.  1.  Kriegschirurgische  hefts.  1916.  (Geliirn-  und  Nerven- 
cMisse,  insbesondere  Spatchirurgie. )  Vorsitzender :  General- 
arzt  Prof.  Dr.  Enderlen.  Erster  Bericliterstatter :  K.  u.  K.  Ad- 
miralstabsarzt  Prof.  Dr.  Freih.  von  Eiselsberg.  Zweiter  Bericli- 
terstatter :  Prof.  Dr.  M.  Borchardt.  Aussprache :  die  Herren  B. 
Payr,  Steiutbal,  Fedor  Krause,  Kleist,  Enderlen,  Tilmann,  Lud- 
loff,  Lobeuhoffer,  Kriiger,  v.  Gaza.  Bruns'  Kriegschirnrgische 
Hefte  der  Beitrage  zur  EUnischcn  chirurgie.  Zwanzigstes  Heft. 
Fiinfter  Band.  Erstes  Heft.  Verhandlnngen  der  Zweiten  Krieg- 
schirurgentagung.  Berlin,  April  26-27,  1916. 

The  treatment  of  skull  and  brain  injuries  belongs  in  large 
measure  not  to  the  surgeons  in  the  first-aid  stations,  but  to 
those  at  some  distance.  The  majority  of  injuries  of  the 
brain  are  of  such  a  nature  that  they  prove  immediately  fatal. 
The  others  come  under  treatment  several  hours  to  a  few  days 
later.  Primary  operation  is  to  be  done  particularly  in  fresh, 
tangential  gunshot  injuries  in  which  conditions  pei'mit. 
Things  necessary  for  proper  treatment  are  (1)  proper  assist- 
ance, (2)  proper  armamentarium,  and  (3)  a  location  such 
that  the  patient  may  remain  on  the  spot  and  not  be  compro- 
mised by  being  transported  for  some  days.  When  these  con- 
ditions can  be  fulfilled,  primary  operation  will  secure  much 
more  rapid  and  smooth  healing  of  the  wounds,  will  diminish 
infection  of  wounds  and  diminish  the  danger  of  later  infec- 
tion, such  as  meningitis  or  encephalitis.  Von  Eiselsberg 
differs  from  Barany,  who  recommends  complete  suture  of 
the  wound.  Von  Eiselsberg  advocates  universal  drainage 
and  loose  suture. 


188  WAR   SURGEEY   OF    THE    NEEVOUS   SYSTEM. 

When  the  skull  injuries  (and  by  skull  injuries,  Von  Eisels- 
berg  means,  always,  gunshot  injuries)  come  to  the  base  hos- 
pitals, the  treatment  will  depend  upon  the  symptoms  which 
the  patient  shows.  The  chief  danger  lies  in  inflammation  of 
the  brain  and  its  meninges.  For  the  most  part  the  patients 
will  come  under  treatment  at  least  24  hours  after  injury  and 
transportation.  Under  these  circumstances,  unless  symp- 
toms demand  immediate  operation^  von  Eiselsherg  believes  it 
better  to  allow  the  patient  a  few  hours''  rest  in  bed,  so  that 
the  general  cond/ition,  the  temperatKre,  epileptiform  seizures 
and  the  local  conditions  of  the  tvound  can  be  observed,  and 
for  X-ray  examination  in  order  to  determine  the  extent  of 
the  bone  injury.  Unless  there  are  severe  general  symptoms 
or  severe  local  symptoms,  von  Eiselsberg  would  not  attempt 
operation  without  an  X-ray  picture.  On  the  other  hand, 
when  there  is  profuse  discharge  from  the  wound  or  when  the 
findings  show  a  marked  disturbance,  such  as  a  paralysis, 
then  an  immediate  operation  is  to  be  recommended. 

The  technic  of  the  operation  is  for  the  most  part  very 
simple.  One  can  operate  under  local  anesthesia,  but  ether 
anesthesia  is  to  be  preferred.  The  most  important  point  is  to 
ascertain  the  extent  of  brain  injury.  In  order  to  do  this, 
one  should  always  bring  as  much  of  the  injured  brain  as  pos- 
sible into  the  field  of  vision.  One  should  remember,  how- 
ever, always  to  handle  the  brain  as  delicately  as  possible, 
and  at  the  same  time  remember  that  it  is  much  more  danger- 
ous to  extensively  explore  the  brain  for  splinters  of  bone 
than  to  allow  such  fragments  to  remain.  It  is  a  general 
principle  that  all  foreign  bodies  shoidd  be  removed,  be- 
cause they  can  always  produce  abscesses.  Of  all  the  instru- 
ments useful  in  exploration  for  bone  fragments  and  foreign 
bodies,  the  very  best  is  the  little  finger.  With  the  smoothing 
up  of  the  bone  margins  and  the  removal  of  foreign  bodies, 
the  operation  is  ended.  The  wound  should  be  drained,  not 
packed,  a  few  stitches  used,  and  a  light,  protective  dressing 
applied. 

When  it  is  demonstrated  during  operation  that  there  is 
no  cortical  pulsation,  this  is  an  indication  of  increased  pres- 
sure, due  ether  to  hemorrhage  or  to  inflammatory  abscesses ; 
and  if  hemorrhage  is  not  present,  then  an  exploratory  in- 
cision should  be  made  through  the  dura  and  into  the  brain. 
A  good  method  of  exploring  the  brain  is  by  puncture  with 
a  thick  needle ;  and  the  needle  must  be  large  because  pus  is 
often  too  thick  to  flow  through  a  small  needle.  Perhaps 
still  better  is  an  incision  with  a  pointed  bistoury.  When 
an  abscess  is  located  in  the  brain  one  should  insert  a  small 
rubber  drain  for  24  to  48  hours.  It  should  be  remembered 
that  pressure  on  the  brain  by  pack  or  drainage  tube  will 
make  a  decubitus  within  a  short  time,  and  it  is  always  neces- 
sary to  remove  drainage  tubes  within  two  days,  or  at  least 
to  shorten  them. 

When  a  brain  abscess  causes  death,  it  is  usually  through 
progressive  softening,  or  on  account  of  perforation  of  the 


FOREIGN   WAR  LITERATURE.  189 

abscess  into  the  ventricle.  Perforation  toward  with  the 
meninges,  with  resulting  meningitis,  does  not  occur  so  often. 
When  on  exposing  the  brain,  meningitis  is  found,  then  the 
opening  should  be  enlarged  in  the  hope  that  the  meningitis 
may  subside.  Unfortunately,  meningitis  usually  does  not 
subside,  or  the  improvement  is  only  local.  The  purulent 
meningitis  spreads  toward  the  base  and  over  the  cortex  and 
usually  can  not  be  influenced  by  operation.  Multiple  punc- 
tures of  the  brain  do  not  seem  to  help.  Spinal  puncture 
serves  mostly  for  a  diagnostic  and  prognostic  agent,  rather 
than  a  therapeutic  help.  Urotropin  does  not  seem  to  be  of 
service  after  meningitis  is  well  developed. 

The  prognosis  is  very  different  in  abscess,  provided  cir- 
cumstances permit  the  drainage  of  the  abscess.  Great  diffi- 
culty is  often  encountered  in  localizing  the  abscess.  Of  65 
deaths  that  occurred  under  von  Eiselberg's  observation  early 
in  the  war,  35  were  the  result  of  abscess.  In  these  deaths 
from  abscess  death  occurred  for  the  most  part  on  account 
of  rupture  of  the  abscess  and  sometimes  on  account  of  pro- 
lapse, von  Eiselberg  here  mentions  the  observation  of  other 
men  who  believe  that  prolapse  which  does  not  show  tendency 
to  subside,  speaks  for  an  abscess  or  a  severe  inflammatory 
process  in  the  depths  of  the  brain. 

In  through-and-through  gunshot  injuries,  von  Eiselberg 
says,  death  usually  occurs  soon  after  injury,  on  account  of 
the  excessive  brain  destruction,  and  operation  does  not 
promise  as  much  as  in  tangentile  injuries,  because  the  entire 
path  of  the  bullet  is  not  accessible  and  removal  of  injured 
tissues  is  quite  as  impossible  as  in  basal  fractures.  Even  so, 
it  may  be  very  worth  while  to  enlarge  and  clean  the  wounds 
of  entrance  and  exit  and  remove  whatever  bone  fragments 
are  accessible. 

A  very  difficult  chapter  is  the  one  concerning  projectiles 
which  remain  in  the  brain.  These  cases  must  be  treated  in 
the  base  hospitals  unless  the  bullet  lies  directly  under  the 
skin.  Naturally,  very  severe  symptoms  of  pressure  demand 
early  operation,  but  in  general  it  is  much  better  that  they 
be  carefully  X-rayed  and  the  location  of  the  projectile  de- 
termined before  operation.  An  extensive  experience  in 
peace  time  taught  that  in  a  large  percentage  of  cases  pro- 
jectiles "heal  in"  without  reaction,  and  it  was  the  opinion 
that  most  projectiles  were  better  unoperated.  It  has  been 
the  experience  of  each  one,  however,  since  the  war  began, 
that  in  the  majority  of  cases  the  projectile  causes  a  local 
abscess,  which  can  be  avoided  by  early  removal.  Occasion- 
ally the  projectile  is  "  healed  in  "  without  reaction,  but  the 
patient  who  carries  a  bullet  in  his  brain  carries,  as  it  were, 
a  "  powder  can,"  which  can  explode  at  any  time.  A  very 
slight  trauma,  an  infectious  disease,  or  anything  which  will 
lower  the  patient's  resistance  will  be  an  opportune  time  for 
a  latent  infection  to  develop  a  virulent  character.  Unfortu- 
nately, we  have  not  yet  learned  in  what  per  cent  of  cases 
the  bullet  will  make  latfer  trouble,  while  in  the  cases  with 


190  WAR    SUEGEEY   OF    THE    NEEVOUS    SYSTEM. 

acute  symptoms  the  necessity  for  operation  can  not  be 
discussed. 

The  surgeon  often  meets  with  the  rather  difficult  question 
as  to  hoAv  far  he  endangers  the  patient  by  attempting  to 
remove  projectiles  which  cause  no  symptoms.  One  may 
divide  ennbedded  in-ojectiles  Into  those  which  rerimin  super- 
ficial and  those  which  remain  in  the  depths.  Those  which 
lie  superficially  can  he  easily  removed  and  a  practised  sur- 
geon may  certainly  attempt  it.  When  they  are  in  the  depths^ 
one  altvays  sees  hefore  his  eyes  the  danger  to  life  in  operat- 
ing. Here  the  surgeon  must  determine  for  himself,  after 
carefully  localizing  the  projectile,  whether  it  will  be  possible 
to  extract  the  projectile  without  irreparably  injuring  the 
brain. 

It  is  very  easy  to  outline  treatment  of  projectiles  which 
are  surrounded  by  abscess.  The  results  of  the  operation, 
however,  are  much  more  doubtful.  In  14  cases  of  foreign 
bodies  with  abscess,  in  not  less  than  half  the  patients  suc- 
cumbed. This  is  quite  sufficient  to  move  one  to  search  for 
the  bullet  at  primary  operation  in  order  to  avoid  late 
abscess. 

The  patient  with  a  projectile  in  the  brain,  even  though 
without  symptoms,  should  be  kept  quiet,  and  possibly 
through  the  rest  infection  will  subside  and  the  projectile 
will  be  better  walled  off.  On  the  other  hand,  it  should  be 
repeated  that  even  an  encapsulated  projectile,  especially 
when  it  is  one  of  the  modern  bullets  or  shrapnel  bullets,  is 
always  a  potential  danger  for  the  patient,  and  the  patient 
should  avoid  every  mental  and  physical  exertion.  As  X-ray 
technic  is  improved  and  the  bullets  can  be  accurately  local- 
ized, much  good  can  be  done  and  the  mortality  very  dis- 
tinctly reduced  through  early  removal  of  projectiles  without 
destructive  operations. 

von  Eiselsberg  again  states  that,  in  his  opinion,  the  most 
difficult  chapter  in  the  treatment  of  gunshots  of  the  skull 
is  that  concerning  the  inflammatory  changes  of  the  brain 
with  the  complications  of  abscess  and  meningitis. 

The  after  treatment  is  also  important.  There  can  be.no 
restoration  of  the  brain  tissue  itself,  and  against  the  pro- 
gressive inflammatory  softening  one  is  absolutely  helpless, 
even  as  he  is  against  the  meningitis.  These  two  factors 
are  responsible  for  most  of  the  bad  results. 

Another  cause  of  bad  result  is  prolapse,  against  which 
the  surgeon  is  also  almost  helpless.  The  prolapse  can  be 
caused  by  a  deep-lying  abscess,  and  through  drainage  the 
condition  may  be  improved.  Prolapse  may,  however,  be 
due  to  a  progressive  inflammation  of  the  brain,  coupled  with 
a  marked  edema,  and  in  many  cases  this  progresses  until 
death  takes  place.  From  a  prognostic  standpoint,  one  may 
divide  prolapse  into  two  forms,  the  unfavorable,  which 
resist  all  treatment,  and  those  which  come  spontaneously  to 
healing  or  heal  after  opening  an  abscess. 

Concerning  the  treatment  of  prolapse,  there  is  no  unity. 
Obviously,  a  pus  focus  should  be  drained.    If  necessary,  the 


FOREIGN    WAR   LITERATURE.  191 

opening  in  the  skull  should  be  enlarged.  The  dressing 
should  be  so  applied  that  all  pressure  on  the  brain  is  avoided, 
and  no  attempt  should  be  made  to  liold  the  prolapse  back 
by  the  use  of  plates  of  bone  or  metal.  The  prolapsed  portion 
should  not  be  removed.  Best  of  all  is  simply  to  allow  the 
prolapse  to  remain  undisturbvid,  and  as  the  iniiammatory 
processes  subside  the  prolapse  will  disappear.  A  light  loose 
dressing  and  daily  application  of  tincture  of  iodin  is  all  the 
treatment  necessary. 

The  later  complications,  such  as  paralysis,  disturbance 
of  speech,  etc.,  should  be  treated  by  medico-mechanical  move- 
ments, speech  lessons,  etc. 

Of  special  importance  is  the  question  of  covering  the 
defect,  and  one  asks :  "  In  which  cases  shall  one  repair  the 
defect  in  the  skull  and  in  Avhich  ones  not  ?  "  These  questions 
are  more  important  than  the  question  of  how  shall  one  cover 
the  defect.  While  it  is  not  necessary  to  repair  small  defects, 
it  is  certainly  better  when  the  brain  is  again  nornudly  in- 
closed in  its  hard,  capsule.  Headaches,  so  long  as  they  lead 
one  to  suspect  the  possibility  of  abscess,  are  a  direct  contra- 
indication to  plastic  operations;  also  a  purulent  discharge 
from  the  wound  contraindicates  operation.  The  scar  is  often 
sufficient  cause  for  repair,  if  it  is  bulging  or  painful  or  shows 
a  tendency  toward  easy  injury.  A  tendency  toward  epilepsy 
is  a  sufficient  indication.  The  cause  of  the  headaches  is  not 
in  all  cases  an  increase  in  brain  pressure.  It  has  been  shown 
that  in  most  cases  there  is  an  increase  in  pressure  of  cerebro- 
spinal fluid ;  in  some  cases  it  is  diminished. 

There  are  two  schools  in  regard  to  the  point  of  doing  skull 
plastics  for  epilepsy.  In  one,  Kocher  warns  against  covering 
a  defect  in  the  skull  when  epilepsy  is  present,  and  he 
relieves  pressure  by  puncturing  the  ventrile;  while  Bunge 
seeks  to  restore  the  normal  conditions  of  the  skull  and  to 
cure  the  epilepsy  by  repairing  the  defect.  Von  Eiselberg  is 
of  the  opinion  that  a  plastic  repair  of  a  defect  in  the  skull 
will  often  bring  more  danger  than  allowing  the  defect  to 
remain  open.  One  should  always  attempt,  by  giving  bro- 
mide preparations,  salt-free  diet,  and  continued  use  of 
luminal,  to  control  tha  epilepsy. 

The  operation  should  have  as  the  objective,  before  all 
things,  to  prevent  scar  formation  and  adhesions  between 
the  brain  and  its  coverings.  Through  the  implantation  of 
celluloid,  or  of  fat,  or  of  omentum,  one  should  attempt  to 
avoid  the  reformation  of  the  scar. 

von  Eiselberg  reports  27  cases  of  operation  for  repair  of 
skull  defects,  of  which  25  healed  after  operation,  one  re- 
quired reopening  of  the  wound,  from  which  the  bony  flap 
was  removed,  and  one  died  of  later  abscess.  Twenty  of 
these  27  cases  were  repaired  by  means  of  a  free  transplant 
of  bone  with  periosteum  from  the  tibia.  The  plastic  oper- 
ations were  undertaken  at  varying  periods  after  the  in- 
jury, the  majority  at  the  sixth  month.  One  should  tcait  a 
long  time  before  closing  the  bone  defect,  on  account  of  the 


192  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM, 

danger  of  develofment  of  late  abscesses.  Of  16  cases  of 
late  abscess,  von  Eiselberg  mentions  three  cases  in  par- 
ticular, who  were  apparently  well  at  six,  eight,  and  ten 
months,  respectively,  after  their  injury,  and  then  devel- 
oped abscesses  which  led  to  death  in  spite  of  the  fact  that 
they  were  properly  diagnosed  and  operations  were  made. 

von  Eiselberg  did  not  see  any  bad  results  from  taking  the 
transplants  from  the  tibia.  Lately  he  has  used  some  sub- 
cutaneous fat  between  the  transplant  and  the  brain,  or  he 
has  put  the  periosteal  surface  toward  the  brain.  Of  27  cases 
in  which  the  transplanted  bone  healed  in  place,  24  healed 
fast,  and  in  one  the  transplanted  bone  is  still  movable. 

von  Eiselberg  quotes  from  Lexer,  who  found  pathogenic 
bacteria  in  scars  many  months  after  operation,  and  on  this 
account  he  would  not  attempt  secondary  skull  plastics  under 
one-half  year,  or,  better,  one  or  two  years. 

In  von  Eiselberg's  opinion  it  can  not  be  sufficiently  em- 
phasized that  patients  with  skull  injuries  must  be  under 
careful  medical  observation  for  a  long  time  and,  when  pos- 
sible, adjacent  to  a  surgical  pavilion,  and  every  exertion 
must  be  avoided  because  the  danger  of  late  abscess  hangs 
always  over  their  heads.  The  vast  majority  of  these  pa- 
tients must  be  discharged  as  unfit  for  duty.  He  offers  the 
following  conclusions : 

1.  The  most  important  and  most  dangerous  complications 
of  gunshot  of  the  skull  are,  after  the  primary  disturbances, 
the  inflammatory  processes  of  the  brain  and  its  meninges. 
Brain  abscesses  are  always  to  be  operated.  In  brain  soft- 
ening and  meningitis,  an  operative  attack  is  almost  hope- 
less, and  the  same  holds  true  for  prtolapse,  except  those  caused 
by  abscess. 

2.  All  tangential  gunshots,  which  show  general  clinical 
symptoms  or  local  symptoms,  or  show  no  tendency  toward 
improvement,  are,  especially  if  the  X  ray  shows  positive 
findings,  to  be  operated. 

3.  Through  and  through  gunshots  in  certain  cases  are  bet- 
ter not  operated.  If  operated,  the  attack  should  onh''  be 
made  in  the  attempt  to  prevent  progressive  inflammation 
and  infection. 

4.  Projectiles  lying  superficially  should  be  removed.  The 
deep-lying  one  should  be  operated  if  the  patient  develops 
symptoms.  The  X  ray  is  an  inval Liable  help.  When  the 
projectiles  heal  in  the  depths  without  symptors,  then  one 
must  determine  according  to  their  location  whether  or  not 
operation  is  to  be  clone. 

5.  Epilepsy  which  occurs  in  connection  with  a  defect  in 
the  skull  should  first  be  handled  by  inner  medicaments,  and 
only  when  this  is  without  result  and  at  a  later  time  can  they 
be  operated.  At  later  operation,  through  interposition  of  fat 
or  celluloid  plates,  one  can  attempt  to  cure  the  epilepsy. 

6.  With  the  attempts  at  repair  of  skull  defects,  one  should 
wait  nt  least  half  a  year  after  t\\(t  subsidence  of  inflammatory 
symptoms. 


FOIiEKJN    WAK    l.fTERATUHK.  193 

7.  All  patients  with  o-imshots  of  the  skull  should  he  imder 
careful  ohservation  foi-  a  long  time  aftei-  coniplete  wound 
healing,  and  AYhene\'er  possible  they  shoidd  not  he  dis- 
charged, hut  kept  in  military  hos])itals,  in  order  that  they 
may  be  protected  should  the  de\elo])niei)t  of  late  :d)s:cesses 
and  epilepsy  occur. 

8.  Patients  with  gunshot  injuries  of  the  skull,  in  which 
the  brain  has  been  injured,  should  almost  without  exception 
lie   eventually   dischai-i>ed.  unfit   for  sei^vice. 


Erdelyi,  E.:  Gunshots  of  the  Head  (  (iter  Scliiulelschiisw  i .  Kreigs- 
c-hiruvgisclie  Hefte  Bellrih/r  r:nr  KlUuxchcn  (liinniiic.  Vierter 
Krieffsridriirgischrr  Band.  { KrictiscliiiKriiiscJK-s  Heft  XV.) 
May,  imO.     i".  57. 

(lunshots  of  the  skull  are  in  the  majority  of  cases  so  severe 
that  they  lead  to  early  death,  and  the  patients  suffering  them 
remain  upon  the  battlefield.  Of  those  that  live  and  submit 
to  treatment  ever}'  one  shoudd  be  regarded  as  infected  and 
every  means  must  be  employed  to  pre\ent  the  wider  spread 
of  the  infection. 

Small,  seemingly  harndess  wounds,  with  sharp  entrance 
and  exit  openings,  may  be  accompanied  by  the  severest  brain 
and  nerve  injuries.  Therefore,  evei-y  gunshot  of  the  skull  is 
a  case  for  operation,  even  if  the  operation  is  nothing  more  oi; 
less  than  a  thorough  toilet  of  the  wounds. 

Exposure  of  the  area  of  injury,  removal  of  foreign  bodies 
and  l)one  fragments,  and  establishment  of  free  drainage  are 
recognized  as  good  practice  in  both  military  and  peace  sur- 
gery. Fui'thermore.  operation  should  he  done  as  rapidly,  as 
thoroughly,  and  as  ideally  as  possible.  Work  half  done  is 
worse  than  absolutely  none,  ancl  a  late  operation,  undertaken 
after  a  prior  operation  poorl}^  done,  renders  the  prognosis 
extremely  bad.  For  the  most  part,  when  the  operations  are 
not  properl}^  done  and  radically  enough  done,  late  operations 
come  too  late  to  be  of  benefit.  An  injured  brain,  lying  in  a 
closed  cavity,  is  ver;\'  susceptible  to  infection. 

The  primary  factors  threatening  life  are  (1)  pressure, 
(2)  infection.  The  pressure  may  be  general  or  local  and 
may  result  from  hemorrhage  or  from  foreign  bodj^  or  from 
depressed  bone  fragments.  The  infection  results  from  bac- 
teria carried  into  the  brain  by  foreign  bodies,  which  may 
be  bidlet,  clothing,  hair,  etc.  Therefore,  the  thorough  re- 
moval of  all  foreign  bodies  and  provision  for  drainage  of 
the  wound  secretion  are  imperative. 

When,  however,  we  undertake  early  operation,  there  arises 
always  the  difficult  question :  Where  shall  we  operate  ? 
For  this  there  is  no  accurate  answer.  It  depends  upon  how 
one  can  arrange  the  field  facilities.  In  any  case,  these  opera- 
tions can  only  be  undertaken  (1)  where  there  is  possibility 
for  complete  asepsis,  (2)  where  assistance  of  the  X  ray  can 
be  had,  and  (3)  where  the  operated  pnitients  can  lie  quietly  for 
a  long  time  after  operation.    Naturally,  it  is  Jiot  always  pos- 

33764—17 W, 


194  WAR   SUEGEKY    OF    THE    NERVOUS    SYSTEM, 

sible  in  the  very  se>ere  cases,  when  life  is  threatened  by  hem- 
orrhage,  to  wait  for  ideal  surroundings,  but  in  these  cases  the 
operation  should  not  be  more  than  a  revision  of  the  wound 
and  provision  for  drainage  and  patient  should  be  immedi- 
ateh^  sent  to  a  location  where  circumstances  for  operation 
and  a  long  post-o^jerative  treatment  are  to  be  had. 

The  following  points  are  to  be  observed  in  operation: 
Hair  must  be  removed,  the  scalp  well  cleansed  with  ben- 
zine, and  tincture  of  iodin  applied  to  the  w^ound  and  the 
surrounding  territory.  It  is  probablj^  better  practice  to 
excise  the  edges  of  the  wound,  particularly  if  ragged  or 
dirty.  Before  the  operation,  give  morphine  and,  if  possible, 
carry  out  the  operation  under  local  anesthesia  of  1  per  cent 
novocaine.  General  anesthesia  in  severe  brain  injuries  is  con- 
traindicated.  Careful  hemostasis  must  be  secured,  either 
by  ligature  or  by  tamponnade.  Sufficient  bone  should  be  re- 
moved to  allow  of  thorough  exploration  of  the  torn  dura. 
Removal  or  elevation  of  all  bone  splinters  or  depressed  frag- 
ments, blood  clots,  should  be  carried  out.  Fragments  of 
brain  should  also  be  carefully  removed,  as  they  decompose 
and  predispose  to  infection.  With  the  gloved  finger,  the 
iniured  brain  should  be  very  carefully  explored  and  \'ery 
often  foreign  bodies  can  be  felt  and  removed.  The  wounds 
should  be  left  wide  open  or  at  least  only  partially  sutured, 
with  adequate  ]n'ovision  for  drainage. 

The  postoperative  treatment  is  very  important;  and 
transportation  should  not  be  undertaken  for  a  long  time,  be- 
cause prolapse  and  infection  are  much  more  apt  to  follow. 
Primary  plastic  operations  must  not  be  done  on  account  of 
the  necessity  for  drainage  and  tlie  danger  of  infection. 
Three  or  four  grams  of  urotropin  should  be  given  daily  as  a 
prophylactic  against  encephalitis  and  meningitis. 

One  must  be  very  careful  in  the  prognosis.  Gunshots  of 
the  skull  must  be  given  a  much  more  serious  progTiosis  than 
in  the  skull  fractures  seen  in  peace  time.  The  reason  for  this 
lies  in  the  much  greater  comminution  of  the  bone  and  in  the 
much  gTeater  injury  of  the  brain,  due  to  the  high  velocity  of 
projectiles.  The  prognosis  depends  upon  the  following- 
factors  : 

(1)  Upon  the  distance  and  the  force  of  the  projectile.  At 
near  distances  the  explosive  force  of  the  projectile,  especi- 
ally in  through-and-through  wounds,  is  very  great  and  leads 
usually  to  rapid  death.  (2)  Upon  the  amount  of  brain 
tissue  injured.  (3)  Upon  th.e  location  of  brain  tissue  in- 
jured. (4)  Upon  the  size  of  the  wound  in  the  dura,  upon 
which  in  large  measure  the  likelihood  of  infection  depends. 
(5)  T"'])on  the  character  of  the  gunshot  injury.  Through-and- 
throngh  gunsb.ots  and  gunshots  in  which  the  projectile  re- 
mains, ai-e  naturally  much  more  dangerous  than  a  tangential 
ii^sjurv.  ((>)  T^]:(()n  the  character  of  the  ])rojectile.  Biillets 
offer  the  best  prognosis ;  shell  f  r;igments.  the  worst  prognosis. 
(T)  Upon  the  time  of  operation.  The  earlier  the  operation, 
tlio  better  tl:'/  proffn.osis. 


FOKEiGX    WAR    LITEKATUKE.  195 

It  should  be  renieiiiht'ied.  howcxer,  that  even  after  com- 
l^lcte  healing  of  tlie  wound  the  pi-()<inosis  uiav  still  be  dis- 
tiii'bed  on  acconnt  (jf  later  coniplieations.  Mich  as  hj-ain  ab- 
scess, wliich  may  develop  after  many  months,  or  epilepsy, 
and  the  paralyses.  Xei'vous  and  jjsychic  distin-bances  also 
develop  in  all  kinds  and  degrees.  Brain  abscesses  may  de- 
velop weeks  or  months  after  the  primary  injury  on  account 
of  infection  in  injured  and  bi'uised  brain  sul)stance  and 
aj'ound  foreign  bodies,  bone  fragments,  etc.  The  differ- 
entiation frcm  ence]3halitis  is  not  always  possible  during  the 
first  8  or  10  days,  but  encephalitis  seldom  develoi)s  after 
the  first  three  weeks. 

The  ])rognosis  in  brain  abscesses  is  not  genei'alh^  good,  Init 
the  abscesses  are  usually  superficial  and  can  be  easily 
drained,  and  on  this  account  olfer  better  prognosis  than 
brain  abscesses  secondary  to  ear  diseases  as  seen  in  peace 
time.  It  should  not  be  forgotten  that  the  patient,  long  after 
apparent  healing,  may  still  develop  a  brain  abscess  around  a 
foreign  Ijody,  and  great  care  must  be  exercised  in  the  dis- 
charge of  these  patients  from  observation  and  in  their  re'is- 
signment  to  active  duty  at  the  front. 

P^nce])halitis  is  one  of  the  most  usual  cc^mplications  lead- 
ing to  (loath.  Usually  it  (  ccurs  early  and  is  difficult  to  diag- 
nose from  meningiti;:;.  in  the  majority  of  cases  progressive, 
and  ends  fatally.  Meningitis  may  be  diffuse,  extending  di- 
rectly from  the  injury,  or  mav  develop  at  the  base.  As  soon 
as  there  is  suspicion  of  meningitis,  spinal  puncture  should 
be  done,  and  if  organisms  are  cultivated  the  wound  shoukl 
be  widely  opened  and  drained.  Laminect(;my  may  be  of 
>'alue.  T'rotropin  should  be  given  in  larger  doses  than  the 
usual  prophylactic  doses. 

Brain  i^rolapse  is  the  expression  of  an  inflammatory  pro- 
cess in  the  brain — meningitis,  encephalitis,  brain  abscess, 
or  their  combination.  It  has  been  observed  that  a  prolapse 
may  appear  because  of  the  too  early  transportation  of 
patient  after  operation.  The  treatment  of  prolapse  of  the 
brain  should  be  expectant.  Aseptic  dressings,  without  pres- 
sure, should  be  applied.  In  every  case,  as  soon  as  the  cause 
disappears,  the  prolapse  wdll  regress.  If  the  prolapse  does 
not  disappear  under  expectant  treatment,  it  means  that  there 
is  "trouble"  in  the  depths. 


Axhausen,  G.:  Technique  of  Cranioplasty  (Zur  Technik  der  Schadel- 
plastik).     Arch.  f.  KVni.  Chir.     P.d.  107,  Hft.  IV,  April,  1916. 

The  vast  majority  of  surgeons  agree  that  the  gunshots 
involving  skull  and  brain  are  l^etter  handled  by  primary 
operation.  It  is  also  recognized  that  after  complete  wound 
healing  the  cfmdition  of  the  patient,  on  accjunt  of  nervous 
distui'bMUces.  does  not  return  to  an  ideal  state  of  health. 
Vei-y  often,  at  the  site  of  injui-y.  there  is  to  l)e  found  a  large, 
tcndei-  scar,  through  the  thin,  middle  portion  of  which 
pulsation  of  the  brain  is  to  be  seen,  a  conditii  n  known  as 
the  ''pulsating  skull   defect."     AVe   knoAv,   fui'ther.  that  on 


196  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

account  of  the  very  poor  osteoo'enetic  capacity  of  the  bone 
of  the  skull,  the  spontaneous  closure  even  of  a  small  defect 
does  not  follow.  In  all  the  cases  operated  by  Axhausen. 
eA-en  in  the  oldest,  there  was  no  attempt  at  formation  of 
new  bone  and  the  margins  of  the  defect  were  almo^-t  as  sharp 
as  when  primary  operation  was  comiDleted.  In  order  to 
secure  complete  restoration  to  !t  normal  condition,  a  second- 
ary filling  of  the  defect  is  necessary.  It  is  obvious  in  th(;se 
cases  in  which  the  symptoms  suggest  the  possibility  of  an 
infectious  process  within  the  slvuU.  no  plastic  o])eratioii 
should  be  undertaken. 

Axhausen  considers  tw(j  possibilities,  the  one  of  the  fla})- 
plastic,  after  Miiller-Konig,  with  variations,  and  the  free 
transplantation.  In  free  transplantation,  various  transplan- 
tation materials  are  at  our  disposal,  but  there  are  really 
very  few  suitable  materials.  Certainly  the  most  suitable  of 
all  is  new  bone — and  bone  from  the  [)atient  himself.  Von 
Eiselberg  declares  that  the  Miiller-Konig  phistic.  or  a  varia- 
tion, stands  in  the  first  line.  Axhausen  differs  from  this 
and  bases  his  opinion  upon  many  cases  which  he  has  ob- 
served in  Kiel  and  in  Berlin.  During  the  last  year,  he  has 
operated  28  cases,  and  he  is  convinced  that  the  best  method 
of  closing  defects  of  the  skull  is  by  the  use  of  the  free  auto- 
plastic operation.  The  Miiller-Konig  plastic  is  technically 
very  difficult.  Anyone  who  has  repeatedly  attem])ted  the 
operation  must  admit  that  to  secure  a  flap  (in  which  the 
plate  of  bone  with  neighboring  scalp  is  attached)  is  not 
at  all  simple.  When  it  is  successful,  one  may  secure  a  thin 
plate  made  up  of  many  broken  pieces,  and  with  this  one 
must  be  satisfied.  The  connection  between  the  bone  plates 
and  the  covering  skin  is  very  loose,  and  it  is  impossible 
without  loosening  the  scalp  from  the  plate  of  bone  to  secure 
an  accurate  coaptation  of  the  transplant  into  the  bony  de- 
fect. On  this  a-'count,  it  is  not  possible  to  secure  an  im- 
mediate union  between  the  implanted  bone  plate  and  the 
surrounding  skull.  On  account  of  the  ])oor  osteogenetic 
capacity  of  the  skull,  it  is  a  long  time  before  these  flaps  are 
healed  tightly.  Then  there  is  an  objection  for  cosmetic 
reasons.  Not  only  is  the  scar  not  diminished,  but  the  throw- 
ing over  of  the  flap  makes  a  larger  and  more  ugly  scar,  which 
often  calls  for  a  new  operation  to  secure  healing.  Either  this 
must  be  closed  by  second  flap  or  by  skin  graft,  and  such 
scars  upon  the  hairy  scalp  are  very  conspicuous. 

Removal  of  a  plate  of  bone  from  the  anterior  surface  of 
the  tiba  is  extremely  simple.  It  is  possible  to  make  the 
plate  of  bone  correspond  accurately  to  the  defect  to  be 
bridged  and  it  can  be  made  of  the  desired  thickness.  One 
needs  no  special  instruments.  Axhausen  has  used  the  ordi- 
narj^,  broad,  sharp  carpenter's  chisel.  In  case  the  defect 
should  be  so  large  as  not  to  be  covered  by  the  width  of 
plate  secured  from  the  tibia,  two  pieces  can  be  implanted 
alongside  each  other.  The  plate  of  bone  from  the  tibia 
should  be  so  implanted  that  it  is  held  firmly  in  the  defect, 
and  it  is  of  much  assistance  in  freshening  the  defect  mar- 


I'OKKICX    WAH    l.l'l  KHATrRK.  197 

gin.s  to  make  a  i'iglit-an<!:!ecl  or  a  trapezoid  foi-ni.  Free 
union  usually  occurs  in  14  days.  When  the  transplanted 
portion  of  bone  is  pi-oiXT-rly  inserted,  no  pei'iosteal  sutures 
for  fixation  are  necessary. 

In  these  27  cases  it  was  possible  to  excise  the  old  scar 
and  by  dissecting  the  ma i gins  free  to  carry  out  direct  sutnre 
of  the  skin  margins  abo\  e  the  transplanted  flap.  ( )n  account 
of  the  very  lich  cii'culation  of  the  skin  of  the  scalp  it  is 
possible  to  do  what  should  not  be  done  in  other  locations, 
and  that  is  to  bring  wound  edges  together  with  some  ten- 
sion. There  was  ne\  er  any  dillictdty  caused  by  taking  bone 
from  the  tibia  :  patients  did  not  complain,  and  particulai'ly 
it  should  be  noticed  that  thei'e  were  never  any  fi-actures. 

Axhaiisen  always  took  i^articnlar  care  that  the  periosteal 
side  of  the  transplant  lay  outward,  so  that  the  suture  line 
did  not  lie  upon  the  bare  bone  but  upon  the  o\erlying 
perioFteum.  The  chiseled  side  of  the  bone  graft  lay  toward 
the  biain.  This  svn'face  was  fairly  smooth,  and  Axhaiisen 
did  not  obser^e  any  excessive  scar  or  callus  formation.  He 
recommends  excision  of  as  much  of  scar  upon  the  brain  as 
possible,  so  that  there  is  distinct  ])ulsation  before  applying 
the  graft. 

Epileptiform  seizures  at  the  close  of  the  operation  were 
not  obser\ed.  It  was  twice  possible,  through  operation,  to 
secure  a  cessation  of  ejMleptic  attacks.  In  two  cases,  imme- 
diately after  the  opeiation.  there  Avere  symptoms  of  paral- 
ysis— in  one  of  the  instances  combined  with  aj^hasia — but 
this  gradually  disappeared. 

The  question  as  to  the  proper  time  to  undertake  opera- 
tion is  fairly  settled.  In  general,  one  must  not  undertake 
plastic  operations  on  the  skull  too  early.  One  should  dis- 
tinguish,the  cases  in  which  there  is  simply  injury  of  bone 
without  cranial  symptoms  from  those  cases  in  w^hich  there 
are  cranial  symptoms,  such  as  paralysis,  aphasia,  etc.  The 
cases  without  cerebral  symptoms  may  be  operated  slightly 
earlier  than  the  others.  In  those  without  cranial  symptoms 
operation  should  be  done  not  before  several  weeks  after  the 
wound  is  perfectly  healed.  Those  in  wdiich  there  is  dis- 
turbance because  of  the  brain  pulsations  may  require  opera- 
tion earlier.  Those  patients  with  cerebral  complications 
should  not  be  operated  until  the  neurologist  has  examined  re- 
peatedly and  offered  some  opinion  as  to  the  character  and 
the  duratif)n  of  the  sympt(mis.  and  then  operation  should 
be  jx>st]K)ne(l  a  few  months  longer.  With  increasing  para- 
lytic symptoms,  also  where  there  is  the  slightest  suspicion 
of  brain  abscess,  it  is  obvious  that  no  plastic  operation 
should  be  undertaken.  Axhausen  regards  epilepsy  as  a  p^^r- 
ticular  indication  for  early  operation. 

Axhausen  operates  tinder  general  anesthesia.  He  objects 
to  local  anesthesia  in  all  plastic  operations,  because  anemia 
is  induced,  and  after  this  secondary  hemorrhage  may  occur 
which  Avill  separate  the  transplant  from  its  surroundings. 
In  young,  healthy  soldiers  he   does  not  see  that   general 


198  WAR    SURGERY    OF    THK    NERVOUS    SYSTEM. 

anesthesia  has  any  danger.  The  typical  operation  he  de- 
scribes as  follows : 

Excision  of  the  existing  scar  in  healthy  skin.  Deepening 
of  the  incision  to  the  bone,  which  should  lie  outside  the 
palpable  defec-t.  Pushing  back  of  the  surrounding  skin 
with  the  pericranium  sufficiently  to  give  a  good  exposure  of 
the  defect.  The  defect  margins  should  then  be  freed  with 
the  periosteal  elevator,  first  from  the  overlying  tissues  and 
then  from  the  tissues  lying  along  the  inner  surface.  There 
should  be  exposure  of  the  whole  extent  of  the  defect;  also 
in  the  angles.  The  defect  should  then  be  smootlied  and 
whatever  scar  is  present  upon  the  brain  should  be  excised. 
The  scar  should  not  be  excised  en  masse,  but  one  layer 
after  anotlier  until  pulsation  of  the  brain  is  seen.  Axhausen 
prefers  leaxing  a  very  thin  layer  of  scar  to  act  as  mem- 
brane between  the  brain  and  the  transplanted  bone.  The 
margins  should  then  be  freshened  with  the  rongeur  and. 
preferably,  the  defect  should  be  made  into  a  right-angled 
or  a  trapezoid  form.  Then  the  skin  flaps  should  be  pre- 
pared for  resuturing.  In  case  there  is  too  much  tension, 
a  parallel  incision  can  be  made  down  to  the  skull  an  inch 
or  two  away  from  the  defect. 

In  taking  the  bone  from  the  tibia,  one  makes  a  con.vex. 
curved,  incision  over  the  anterior  surface  of  the  tibia  im- 
mediately below  the  tuberosity,  with  the  base  of  the  flap 
lying  along  the  course  of  the  tibia.  The  flap  is  then  thrown 
back,  exposing  the  periosteum.  The  periosteum  is  then  in- 
cised to  the  bone,  somewhat  more  periosteum  being  taken 
than  bone.  Chisel  is  then  used  and  driven  forward  with 
the  hammer  so  as  to  remove  a  thin  shell  of  bone.  The  chisel 
should  be  sufficiently  wide,  if  possible,  to  permit  the  entire 
bone  transplant  being  taken  in  one  piece.  A  sponge  should 
be  held  lightly  against  the  piece  of  bone  being  removed, 
because  sometimes  it  jumps  out  and  is  lost.  While  the 
assistant  closes  the  wound  in  the  tibia,  the  bone  transplant 
should  be  trimmed  to  the  proper  shape  and  size  and  fitted 
accurately  into  the  defect;  should  be  pressed  firmly  into 
place,  and  the  scalp  closed  with  interrupted  sutures. 


Perls,  J.:  Symptomatology  and  Treatment  of  Gunshot  Injuries  of 
the  Skull  (Beitrag  zur  Symptouiatologie  iind  Tlieraiiie  der  Scha- 
(leischtisse ) .  Beitrdge  zur  Klinitichen  Cliirurgic.  i Kricfi-'^rhiiirr- 
(/isciies  Heft  XXXl'lI.)     March,  1917,  p.  435. 

Perls's  article  is  based  upon  his  experience  in  the  treat- 
ment of  42  cases  of  skull  injuries  in  Munich,  most  of  which 
have  been  first  treated  in  field  hospitals  and  sent  to  him 
several  weeks  after  their  injury  with  wounds  clean  and  heal- 
ing, or  completely  healed.  From  these  42  cases.  o(\  skull 
plastics  were  made. 

The  local  findings  in  tliese  healed  cases  of  skull  injui'ies 
were  typical.  He  found  a  thin  scar  in  the  region  of  which 
a  bone  defect  was  ]^resent  and  the  sc'ar  distinctly  pulsated 


FOKEIGN    WAR    LITERATURE.  199 

witli  buliiiiio'  (,11  coughing.  Tlie  size  of  tlic  (k'tV'ct^^  in  the 
l)oi)e  was  uj)  to  as  large  as  the  ])ahii  of  the  hand.  He 
quotes  Reich.  Avho  describes  the  scar  as  follows;  Adhesions 
bind  the  supei'ficial  surface  of  the  bi-ain  with  the  uiaririns 
of  the  bone  defect  and  thus  close  otJ'  the  subdural  space: 
on  this  account  the  free  suspension  of  the  l)raiii  in  the 
arachnoidal  fluid  is  interfered  with,  so  that  by  every  pul«;i- 
tion  and  bulging  there  is  irritation  of  brain,  and  this  he 
believes  leads  to  the  development  of  traumatic  epilepsy. 
Beneath  the  superficial  scar  lies  a  characteristi-c  layer  of 
edematous  tissue,  not  a  typical  cyst,  but  resulting,  evidently, 
from  interference  with  the  lymph  drainage  and  disturb- 
ance of  circulation.  This  cystic  layer  is  not  ])ermanent  and 
becomes  further  organized  as  a  scar,  which  l^ecomes  a  typi- 
cal scar  cyst. 

Perls's  remarks  that  although  several  histories  showed  that 
there  had  been  an  unusnally  large  loss  of  brain  substance, 
he  never  found  beneath  the  scar  a  large  defect  resulting 
from  the  loss  of  brain  substance.  He  explains  this  by  "  an 
inner  brain  prolapse."  By  this  he  means  that  the  loss  is 
compensated  for  by  a  displacement  of  brain  substance  into 
the  defect,  possibly  on  account  of  increase  of  ventricular 
fluids. 

He  saw  at  operation  very  often  an  increase  of  fluid  and 
occasionally  a  communication  with  the  ventricle.  In  one 
case  there  was  pronounced  discharge  of  fluid  for  six  days 
after  operation,  and  at  autopsy  a  Avide  communication  with 
the  lateral  ventricle  was  found. 

The  scar  in  the  brain  itself  does  not  lend  itself  to  operative 
attack,  because  naturally  a  fresh  scar  would  form. 

The  (juestion  as  to  whether  ganglion  cells  really  h-eal  he 
does  not  attempt  to  decide,  but  is  of  the  opinion  that  func- 
tion is  taken  over  by  other  cells.  The  resorption  of  diseased 
brain  tissue  takes  place  slowly  and  extends  possibly  over  a 
period  of  years. 

Epilepsy  developed  in  6  of  his  53  cases,  and  he  believes 
that  as  time  goes  by  a  greater  number  will  develop.  Perls 
does  not  believe  that  increased  pressure  is  responsible  for 
epilepsy,  but  rather  that  epilepsy  results  in  increased  pres- 
sui'e,  and  he  differs  from  Wilms,  who  believes  that  epilepsy 
may  result  directly  from  the  increase  of  pressure  due  to  a 
plastic  operation  for  covering  a  defect.  He  believes  that 
the  epilepsy  is  due  to  the  adhesions  at  the  site  of  the  scar 
and  that  the  disturbance  of  the  brain  by  each  pulsation,  by 
straining,  by  coughing,  bending,  makes  continuous  irritation 
on  the  brain,  and  that  epilepsy  results  from  this.  Localized 
spasms  or  convulsions  he  saw  only  when  the  injuries  were  in 
the  motor  cortex.  In  the  vast  majority  of  cases  convulsions 
were  general. 

In  setting  indications  for  operation  in  skull  injuries  with 
resulting  defects  he  advises  plastic  operations  in  all  large 
defects,  and  in  those  cases  where  there  is  distinct  pulsation 
and  bulging  of  the  scar  by  coughing,  etc.,  and  in  every  case 
where  the  location  of  the  defect  exposes  it  to  danger.     As 


200  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

to  the  question  of  whether  skull  plastics  are  imlicatetl  in  epi- 
lepsy, he  belieYes  that  operation  should  he  done. 

Perls  repairs  the  defect  in  the  hone  hy  the  method  of 
(larre;  U-shaped  incision,  throwing-  hack  the  scalp,  when  the 
margins  of  the  defect  are  freshened:  and  then  ])erio.-tea1 
liaps  marked  out,  with  the  base  neai'  the  defect,  the  perios- 
teum reflected  slightly:  and  then,  with  a  flat  chisel,  a  hone 
plate  is  loosened,  and  this  lione- periosteum  fla]:)  is  simply 
turned  over,  with  the  periosteum  toward  the  brain,  in  order 
to  form  an  ai'tificial  dura  and  ])revent  adhesions  l)etween  the 
bone  and  the  brain  scar.  He  reconniiends  local  anesthesia 
-and  emj)hasizes  the  necessity  foi*  careful  hemostasis.  The 
bone  flap  should  consist  only  of  the  outei-  table,  and  opera- 
tion should  not  be  niidertaken  in  anj^  case  earlier  than  six 
\vt«ks  after  complete  healing  of  the  wound. 

In  most  cases  the  headache,  the  dizziness,  etc..  were  j-e- 
lieved  after  the  defects  had  been  repaired,  and  the  epilepsy 
was  relieved  in  half  the  cases,  although  Perls  admits  that 
epileps}^  may  ])ossibly  recur. 

Perls  also  emphasizes  the  fact  that  the  treatment  of  skull 
injuries  does  not  end  when  the  defects  have  been  repaired. 
Through  systematic  exercises  and  education  the  patient  must 
he  brought  again  into  the  very  best  mental  and  physical  con- 
dition, so  that  the  injured  portion  of  brain  may  have  its 
functions  taken  over  by  the  uninjured  portion.  This  can 
best  be  done,  not  in  a  surgical  hospital,  but  in  a  specially  or- 
ganized institution  with  special  teachers  nnd  doctors.  He 
remarks  further  that  the  later  educational  measures  are  to 
be  undertaken  with  the  idea,  that  the  brains  to  be  dealt  with 
are  not  diseased  brains,  such  as  fill  institutions  in  peace 
times,  but  rather  "  crippled  brains.'' 


Guleke,  Prof.:  Skull  Injuries   (Schadelschnssei.     liritrdf/e  zm-  Klin- 
ischen  Chirurgie.     (Krieff'^chirurfnsches  Heft  V/T. )     IMarch,  1916. 

Guleke  takes  up  the  question,  in  which  cases  of  gunshots 
of  the  skull  operative  treatment  should  be  instituted.  He 
believes  that  since  severe  injuries  may  appear  as  simple  in- 
juries of  the  soft  parts  and  a  severe  injury  may  not  be 
recognized,  it  is  a  principle  not  to  be  departed  from  to  ex- 
plore every  injury  to  determine  the  degree  of  bone  injury. 
One  is  very  often  surprised  at  the  unexpected  degree  of 
comminution  of  the  skull  and  at  the  extent  of  laceration 
of  the  brain.  All  depressed  and  loose  pieces  of  bone  must 
be  removed,  the  opening  in  the  bone  must  be  sufficiently 
large  to  disclose  the  extent  of  the  injury  to  the  dura,  and 
the  dura  must  be  opened  sufficiently  wide  to  expose  the  in- 
jured portion  of  the  brain. 

Guleke  is  also  an  enthusiastic  supporter  of  the  principle 
of  primary  operation.  By  primary  operation,  he  means 
operation  at  the  earliest  possible  time  where  localization  of 
foreign  bodies  can  be  done  w^ith  X-ra^",  where  operation 
can  be  performed  under  aseptic  conditions.     He  lays  down 


FOREIGN    WAK    LITERATUKE.  201 

the  rule  that  ^yhen  possible  every  foreign  body  should  be 
removed  at  this  primary  operation  on  account  of  the  grave 
danger  of  later  abscess  formation,  even  though  the  patient 
should  recover  from  the  primary  injury  and  operation. 

The  complications  most  to  be  fear(^d  arc  progressive  en- 
cephalitis, purulent  meningitis,  later  abscess,  and  epilepsy. 
Late  development  of  epilepsy  he  has  not  been  able  to  pre- 
dict, because  it  has  developed  after  apparently  slight  and 
superficial  injuries,  while  in  many  seemingly  vavy  severe 
injuries  it  did  not  follow.  He  emphasizes  \ery  strongly 
the  danger  of  permitting  patients  with  severe  injuries  of 
the  skull,  particularly  with  extensive  brain  injur}^,  to  re- 
turn again  to  the  fiont.  He  favors,  on  the  other  hand,  their 
being  kept  at  home,  and  only  aftei-  a  long  period  should 
they  be  permitted  again  to  engage  in  active  duty. 

His  conclusions  are  as  follows:  (1)  Every  wound  of 
the  skidl  should  be  primarily  operated  and  at  least  the 
wound  edges  should  be  excised  and  the  bone  splinters  re- 
moved. (2)  In  through  and  through  gunshots  and  in  cer- 
tain cases  where  the  projectile  remains  in  the  brain,  one 
may  postpone  operation,  but  in  the  vast  majority  of  cases 
primary  operation  should  be  undertaken.  (3)  Operation 
should  be  made  early,  as  soon  as  asepsis  can  be  secured, 
because  delayed  operation  increases  both  the  immediate 
operative  mortality  and  the  late  complications.  (4)  After 
the  wound  is  enlarged,  sufficient  drainage  is  the  most  im- 
portant part  of  the  after-treatment.  An  early  closure  of 
the  wound  flaps  is  to  be  guarded  against  on  account  of  the 
danger  of  retention,  abscess,  cyst  formation,  etc.  (5)  Pri- 
mary suture  and,  above  all,  primary  plastic  operations  are 
to  be  avoided.  (6)  Brain  prolapse  requires  only  expectant 
treatment,  unless  it  increases,  or  is  indicative  of  deep  ab- 
scess. In  these  cases  the  skull  openings  should  be  enlarged 
and  the  abscesses  in  the  depths  should  be  drained.  (7)  The 
number  of  late  complications  is  very  great  and  the  prognosis 
in  gunshots  of  the  skull  can,  therefore,  not  be  too  cautious. 


Joseph,  E,:  Operative  Treatment  of  Fresh  Gunshot  Injuries  of  the 
Skull     (Die    Operative    Behandlung    Frischer    Scliadelschiisse). 
Beit.  z.  Klin.  Chir.  Band  7.     (Kriegschirurgisches  Heft  XXXIII.) 
March,  1917,  p.  4.52. 

Joseph  says  that  in  making  diagnosis  and  in  deciding 
upon  operative  indications  for  fresh  skull  injuries  one  nmst 
pay  particular  attention  to  the  charact'.'r  of  the  woiuid  and 
to  the  clinical  symptoms.  Especially  is  this  true  since 
toward  tlie  fi'ont  lines  X-r;>y  apparatus  is  often  not  at  one's 
disposal.  After  gunshots  of  head,  patients  are  brought  to 
the  surgeon  in  varying  conditions.  fJoseph  wariw  ])articu- 
larly  against  carelessness  in  the  first  examinations,  because 
a  suiail  wound  may  be  overlooked,  or  a  wound  which  ap- 
})ears  to  be  very  simple  uiay  be  \ery  serious.  He  has  even 
seen  cases  in  wliich  I  he  slcull  iippcared  to  be  intact,  or  witli 


202  WAR    SUBGERY    OF    THE    NERVOUS    SYSTEM. 

nothing-  more  than  a  fissure,  \\lien  in  reality  the  inner  table 
was  nnich  comminnted  and  the  brain  severely  injured.  So, 
also,  the  absence  of  cerebral  symptoms  does  not  warrant,  in 
iill  cases,  considerino;  the  wound  as  harmless. 

Joseph  ad  rises  irhe)i  poss'thle  that  patients  be  transported 
away  from,  the  front  for  operation^  and  that  operations 
should  not  be  undertaken  in  the  dressing  stations  or  front 
hospitals  nnless  there  is  X-ray  apparatus  and  unless  they 
are  in  a  position  to  keep  patients  lying  quietly  for  a  long 
time  after  operation.  He  has  seen  much  harm  done  in 
transporting  ])atients  inmiediately  after  operation,  and  he 
l)elieves  operation  for  gunshot  of  the  head  should  be  done 
in  front  hospitals  only  >Yhen  the  life  is  directly  threatened 
by  hemorrhage  or  jiressure.  In  all  other  cases  patient 
shoidd  be  transported  well  to  the  rear,  where  X-ray  plates 
can  be  made  and  where  there  are  assurances  of  a  long  rest 
in  bed  after  operation. 

When  operation  Twust  he  done  he  recommiends  that  the 
hone  edges  he  smoothed  and  that  such  fragments  of  foreign 
hody  or  hone  fragments  as  can  he  easily  located  he  removed 
and'  that  the  awvnd  he  left  wide  open.  In  Joseph's  experi- 
ence an  incomplete  first  operation  is  worse  than  no  opera- 
tion, and  in  all  the  cases  in  which  incomplete  first  operation 
was  followed  by  a"  second  operation  patients  died  from 
infection.  Insertion  of  drains  into  the  brain  itself  is  ad- 
vised against,  because  infection  may  be  led  in.  All  drains 
should  be  removed  within  two  or  three  days. 

In  discussing  prolapse  of  the  brain  Joseph  says  that  in  his 
experience  the  skin  edges  gradually  covered  over  the  pro- 
lapsed brain,  and  that  through  contraction  of  scar  tissue  was 
graduall,y  pushed  back  within  the  skull. 

Joseph  operated  49  gunshots  of  the  skull.  Of  these,  21 
died.  As  causes  of  death  he  ascribes  infectious  encephalitis 
and  meningitis,  also  tetanus  in  two  instances. 


Exigencies  of  time  have  prevented  including  Italian  literature. 
The  following  abstract,  however,  is  included  because  it  represents 
opinion  expressed  after  the  late  Italian  drive  (August.  191T)  and 
furnishes  highly  interesting  mortality  statistics : 

MaccaUruni,  F.:  Treatment  of  Gunshot  Injuries  of  the  Head  (Trat- 

taiiiento  delle  ferite  :il  cranio.)      Pciisiero  mediro,  ISIilano,  1917, 
VII.  pp.  286,  313. 

Maccabruni's  hospital  usually  received  the  wounded  men  a 
few  hours  after  the  wound  was  inflicted,  as  they  were  directly 
transported  from  the  front  by  automobile.  Many  of  these 
men  arrived  still  under  shock  produced  either  by  psychical 
trauma  of  the  battle  or  by  that  of  the  M^ound. 

Among  these  he  had  occasion  to  perform  44  operations 
on  the  head  from  August,  1916,  to  March,  1917.    Most  often 


r()Kl::i(iX    VVAK    l.l'IKHA'JL'HJ':.  203 

it  \v;is  ail  ••  alypjcal  ci'aiiioetoinv."'  biK  soiiH'tiiiii-s  lie  liad  tu 
perform  a  true  craniectomy. 

Of  44  cases  opei-ated  upon  li^  sliowed  no  lesion  o1  the  dura 
mater,  in  32  cases  there  was  a  lesion  of  the  meninges  and  of 
the  brain;  in  V2  cases  there  was  retention  of  the  i)rojectile, 
in  the  other  3'2  this  was  not  the  case.  Almost  all  wounds 
ended  blind;  some  were  tangential;  only  8  had  a  complete 
canal,  and  of  these  1  was  caused  by  gunshot,  the  other  2  by 
shrapnel  bullets.  With  regard  to  the  region  injured,  the 
wound  of  entrance  was  10  times  in  the  frontal  region,  24  m 
the  parietal  region,  8  in  the  temporal  region,  and  7  in  the 
occipital  region. 

As  to  the  injuring  agent,  the  wounds  were  divided  as 
follows:  Twenty-five  from  fragments  of  shells.  I  from  a 
stone  projected  by  a  shell,  8  from  shrapnel  bullets,  (>  from 
gunshot  projectiles,  2  from  bombs,  2  from  the  explosion  of 
a  mine.     Maccabruni  draws  the  following  conciusions: 

1.  Systematic  intervention  in  all  penetrating  wounds  is 
necessary:  only  a  \ery  few  cases  make  an  exception  to  this 
rule. 

2.  The  operations  should  be  performed  immediately.  The 
sooner  the  intervention  the  better  the  probability  of  good 
results. 

3.  It  is  adAisable  to  examine  the  nervous  system  in  every 
case,  avoiding  tiring  the  patient. 

4.  The  radiological  examination  should  in  almost  all  cases 
precede  the  operation  to  obtain  as  exact  a  location  as  possible 
of  the  intracerebral  projectile. 

5.  The  osseous  defect  should  be  reduced  to  a  minimum; 
it  should  be  a  few  millimeters  larger  than  the  meningeal 
lesion. 

6.  All  bony  fragments  projected  into  the  brain  should  be 
extracted:  the  epidural  space  should  also  be  carefully  ex- 
plored. 

7.  Deep-lying  projectiles  should  be  early  extracted  when- 
ever their  removal  is  ])ossible  without  producing  greater 
damage. 

8.  In  cases  of  vast  wounds  with  tearing  of  brain  substance 
drainage  with  gauze  is  extremely  useful. 

9.  In  all  cases  where  the  wound  is  probably  infected, 
i.  e.,  in  the  great  majority  of  cases,  the  suture  of  the  skin 
of  the  scalp  should  not  be  completely  carried  out. 

10.  The  suture  of  the  dura  mater  should  be  reduced  to  a 
minimum. 

11.  In  lesions  of  the  large  sinuses,  when  hemorrhage  can 
not  be  stopped  with  simply  tamponing,  it  is  best  to  use  a 
suture,  limiting  the  use  of  forcipressure  to  cases  of  extreme 
gravity  and  urgency. 

12.  Bandaging  shoidd  be  renewed  as  rarely  as  possible. 

13.  The  rules  of  the  most  scrupulous  asepsis  should  be 
followed  in  bandaging  as  well  as  in  the  operation. 


204  WAR    SURGERY    OF    THE    iCERVOUS    SYSTEM. 

14.  The  small  cerebral  hernias  are  reduced  with  compres- 
sive treatment;  in  large  liernias  all,  attempts  at  rednction 
should  be  omitted. 

15.  If  the  existence  of  a  cerebral  abscess  has  been  diag- 
nosed it  shoidd  at  once  be  opened  and  drained. 

16.  The  nursing  of  the  patients  shonld  be  most  careful. 

17.  The  patients  should  not  be  removed  until  a  complete 
surgical  cure. 

18.  The  greater  part  of  the  deaths  was  due  to  the  lesion 
itself;  less  frequently  to  meningoencephalitis,  suppurating 
cerebral  hernia,  and  cerebral  abscess. 

Cases  of  opening  of  a  ventricle,  of  hydrorrhea,  ependy- 
mitis,  and  consecutive  encephalitis  were  almost  always  fatal. 

Of  44  cases  operated  upon  16  died.  All  cases  of  death 
belong  to  penetrating  wounds  with  lesion  of  the  dura  mater 
and  protrusion  of  cerebral  substance.  No  case  of  penetrat- 
ing wound  of  the  head  without  infection  of  the  meninges 
died. 


ChaI'TKI;   11. 

Sl'EGERY  OF  THE  SPINE,  SPINAL  CORD,  AND 

ITS  MEMBRANES. 


(Piirts    1-5   fioiu    Diseases   of    llie    .Spinal    C'-oril    and    Its    Meninges,   by,  Chas. 
A.  Elsbebg,  M.  D.     Published  by  W.  B.  Saunders  Company.) 


Part  1. 


THE  SURGICAL  ANATOMY  OF  THE  VERTEBRAL  COLUMN 
AND  SPINAL  CORD. 

THE  VEETEBRAL  COLUMN. 

The  treatnient  of  diseases  of  the  sphial  cord  will  often  require  the 
exposure  of  the  cord  by  removal  of  the  spinous  processes  and  laminae 
of  one  or  of  a  number  of  Aertebrcv.  A  thorough  knowledge  of  the 
structure  of  the  bones  which  make  up  the  vertebral  column  and  of 
the  ligaments  and  muscles  which  bind  them  together  is  therefore 
necessary.  For  a  detailed  account  of  these  structures  the  reader  is 
referred  to  text-books  of  anatomy.  In  the  following,  reference  will 
be  made  to  a  few  facts  of  practical  importance. 

In  the  cervical  and  upper  dorsal  regions  the  vertebrae  are  smaller 
than  in  the  other  parts  of  the  spinal  column.  The  spinous  processes 
of  the  cervical  vertebra  are  bifid  at  their  tips,  but  the  vertebra  do 
not  fit  closely  upon  one  another  and  are  rather  freely  movable  the 
one  upon  the  other.  This  makes  the  removal  of  spinous  processes  and 
laminae  the  most  easy  in  the  cervical  region.  In  the  dorsal  vertebrae 
the  lamina  and  spines  overlap  and  the  vertebrae  are  more  fixed  upon 
each  other.  The  spinous  processes  point  markedly  downward,  so  that 
the  distance  between  the  tips  of  the  spinous  processes  and  corre- 
sponding segments  of  the  cord  is  greater  than  in  the  cervical  region. 
In  the  lower  dorsal  and  lumbar  vertebra  the  spinous  proc;esses  and 
lamina  are  thick  and  short;  the  spines  point  directly  backward  and 
are  deeply  placed  between  thick  muscles.  In  this  region  the  expo- 
sure  of  the  dura  in  the  operation  of  laminectomy  is  a  more  tedious 

205 

IV-VKT   I. 


206  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

procedure ;  the  thick,  short  lamintE  have  to  be  removed  to  the  trans- 
verse and  sometimes  into  the  articuhir  processes  before  a  wide  ex- 
posure of  the  field  of  operation  is  oi>tained. 

The  dorsal  and  lumbar  vertebra-  are  only  sliohtly  moxable  upon 
each  other.  AVhen  a  fracture  of  the  vertebi-a'  occurs  in  this  regioi\. 
the  injury  to  the  spinal  cord  is  not  of  necessity  a  great  one.  In  the 
cervical  region,  hov'ever.  the  great  mol)ility  of  the  vertebrte  upon 
each  other  will  allow  of  miu-h  dislocation,  so  that  severe  crushing 
injuries  with  or  without  fracture  are  of  more  frequent  occin-rence. 

THE  SPINAL  CORD  AND  NERVE  ROOTS. 

The  spinal  rord  is  about  45  cui.  long:  it  extends  from  the  margin 
of  the  foramen  magnum  to  the  lower  part  of  the  body  of  the  first 
lumbar  vertebi-a.  At  its  lower  end  it  tapers  c(mically  (the  conus  me- 
dullaris)  to  end  in  a  slender  filament  (the  filum  terminale).  The 
lower  end  of  the  conus  may  extend  only  to  the  tvrelfth  dorsal  or  as 
low  as  the  middle  of  the  body  of  the  second  lumbar  vertebra. 

In  the  fetus  the  cord  extends  to  the  lower  end  of  the  spinal  canal. 
.Vfter  the  third  month  the  canal  grows  in  length  more  rapidly  than 
the  spinal  cord,  so  that  at  birth  the  ti]i  of  the  conus  lies  at  the  level 
of  the  third  lumbar  vertebra.  Tlie  changes  in  the  ]-eIationship  be- 
tween the  spinal  canal  and  the  lower  end  of  the  cord  and  the  nerves 
of  the  Cauda  equina  in  the  fetus  and  in  post-natal  life  have  an  im- 
portant bearing  upon  the  symptoms  of  some  pathological  conditions. 

On  section  the  cord  is  almost  circular,  being,  however,  slightly 
flattened  from  before  backward.  The  cervical  and  lumbar  enlarge- 
ments are  almost  entirely  due  to  an  expansion  in  a  transverse  direc- 
tion. The  cervical  enlargement  extends  from  the  upper  part  of  the 
cord  to  the  level  of  the  body  of  the  second  thoracic  vertebra,  while 
the  lumbar  enlargement  begins  at  the  tenth  and  is  largest  opposite 
the  twelfth  thoracic  vertebra.  The  enlargements  of  the  spinal  cord 
are  related  to  the  large  nerves  which  supply  the  upper  and  lower 
limbs.  The  relative  size  of  the  different  parts  of  the  spinal  cord 
must  be  well  understood  for  the  proper  recogTiition  of  increase  in 
size  due  to  intramedullary  fluid  or  tumors,  or  decrease  in  size  due 
to  sclerotic  changes. 

Somewhat  arbitrarily,  the  cord  is  divided  into  segments,  each  por- 
tion which  corresponds  to  the  attachments  of  a  pair  of  spinal  nerve 
roots  being  termed  a  segment.  The  nerve  roots  are,  there foie.  the 
guides  to  the  segments  of  the  cord,  the  l^oundaries  of  each  segment 
corresponding  to  a  horizontal  plane  through  the  cord  midv.ay  be- 
tween two  adjacent  nerve  roots.  There  ai'e  thirty-one  pairs  of  spinal 
nerves — eight  cer\ical.  twelve  dorsal  or  thoracic,  five  lumbar,  five 
sacral,  one  coccygeal.    The  first  pair  of  cervical  nerves  emerge  front 


ANATOMY    OF    SPINAL    COLUMN    AND    CORD,  207 

the  \ei'tebrji]  csinal  betw  ecu  tlie  occipital  hone  and  the  atlas;  the 
Hi'st  to  ei<>lit)i  cciNica!  loots  arc  named  after  the  lower  of  the  two 
N'erteljne  which  form  the  inlei'\eitebi'al  foi'ameu  (d'  exit  of  the  nerve. 
The  eighth  cervical  iier\e  i-oots  emerge  from  the  forajnen  l)etAveeii  the 
seveiitli  cerxical  and  Hrst  thoi-acic  \er;el)ia'.  In  the  thoracic,  lumbar, 
and  sacral  areas  the  s])inal  nerves  are  named  aftei-  the  upper  of  the 
(wo  \ertel)raa'  which  foini  the  corresponding-  intei-\ertebral  foramen. 

Kach  spinal  ner\e  is  formed  by  the  coalescence  of  two  roots  which 
s[)i'ing  fi-om  tlie  lateral  aspects  ot  the  cord,  the  anterior  oi-  motor  root 
which  originates  from  the  anterolateral  groo\'e  and  the  posterior  or 
sensory  root  from  the  posterolateral  groove.  The  anterior  and  pos- 
terior roots  perfoi'ate  the  dural  sheath  separately  with  a  thin  septum 
of  dura  mater  betweer^  tiiem.  In  the  cer\ical  !vgion  the  nerve 
bundles  remain  distinct  until  they  have  passed  through  the  dura. 
The  bundles  are  spread  out  like  a  fan,  the  broadest  part  being  at  the 
cord.  At  their  origin  the  bundles  are  spread  out  so  as  to  oi-cupy  L 
to  2  cm.  of  the  cord:  between  vheir  origin  and  the  dura  thev^  lie  closer 
together,  forming  a  laj^er  1  to  1*  cm.  in  breadth;  at  the  dural  open- 
ing the  nerve  bundles  are  stdl  distinct.  In  the  dorsal  and  lumbar 
regions  the  arrangement  is  different  from  that  just  described;  the 
separate  bundles  soon  unite  to  foini  one  bundle  which  ])asses  outward 
to  the  dural  opening. 

From  this  arrangement  it  is  clear  that  in  the  cervical  region  a 
tumor  may,  for  a  long  time,  ULake  pressure  upon  only  a  few  of  the 
bundles  wdiich  go  to  jnako  up  a  posterior  or  anterior  root.  In  the 
dorsal  and  lumbar  regions  the  nerve  bundles  are  united  into  one 
nerve  near  the  cord;  a  tumor  in  these  regions  may  press  upon  the 
whole  nerve  root  from  the  very  beginning  of  its  growth.  Clinical 
experience  agrees  with  these  anatomical  facts;  the  earliest  symptoms 
of  pressure  upon  a  cervical  nerve  root  are  usually  confined  to  a 
small  area  of  distribution,  one  or  two  fingers,  for  example,  while  in 
the  dorsal  or  lumbar  region  the  classical  root  symptoms  extend  over 
an  entire  root  area.  It  is  more  exact,  therefore,  to  distinguish  be- 
tween "  root  bundle "  and  "  root "  symptoms,  and  this  distinction 
should  be  of  clinical  value. 

There  are  marked  differences  between  the  course  of  the  spinal  roots 
at  different  levels.  In  the  cervical  and  upper  dorsal  regions  the 
nerve  l)undles  unite  to  form  the  posterior  root  which  passes  out  of 
the  dural  sac  at  almost  a  right  angle  to  the  cord.  The  root  then 
])t'rf(!rates  the  dura  and  enters  the  posterior  ganglion.  From  the 
ganglion  each  loot  i)asses  outward  with  a  slight  inclination  upw^ard. 

From  the  eighth  cervical  to  the  middorsal  regions  the  course  of  the 
posterioi-  roots  is  different.  Each  root  has  an  inclination  downward 
until  it  nears  the  dura:  it  bends  upAvard  at  an  angle  just  as  it  per- 


208  WAR    SURGEEY    OF    THE    NERVOUS    SYSTEM. 

forates  the  dura.  In  the  middorsal  region  this  angle  is  often  very 
acute — 40°  to  io"".  Beyond  the  ganglion  each  posterior  root  passes 
markedly  upward  before  it  divides  into  its  anterior  and  posterior 
branches. 

In  the  lower  dorsal  and  lumbar  regions  the  posterior  nerve  roots 
pass  downward  and  outward  and  perforate  the  dura;  beyond  the 
ganglia  the  direction  remains  unchanged  until  the  nerve  roots  divide 
into  their  anterior  and  posterior  branches.  The  course  of  the  an- 
terior I'oots  corresponds  to  those  of  the  posterior  roots. 

Taking  into  account  the  peculiar  course  of  the  ner^e  roots  just 
mentioned,  and  the  sensitive  dura,  it  is  eas}^  to  understand  why  a 
small  metastatic  focus  of  malignant  disease  in  the  posterior  and 
lateral  part  of  the  body  of  a  vertebra  may  cause  those  as^onizing 
root  pains  from  which  the  patients  suffer.  It  is  clear  that  only  a 
slight  inflammatory  process  near  the  dural  opening  uiay  l)e  respon- 
sible for  the  occurrence  of  marked  root  symptoms. 

It  is  probable  that  the  movements  of  the  vertebral  column  (bend- 
ing backward  and  forward)  will  increa.se  an  existing  pressure  upori 
any  of  the  lower  dorsal  and  lumbar  posterior  roots,  because  these 
can  not  ,yield  as  easily  as  the  upper  dorsal  roots.  Root  symptoms 
in  the  lower  dorsal  and  upper  lumbar  regions  should  become  much 
intensified  with  forward  and  backward  movements  of  the  vertebral 
column.  To  a  less  degree  this  must  also  be  the  case  in  the  cervical 
region,  although  here  the  bundles  of  the  posterior  roots  are  spread 
over  such  a  large  area  that  all  are  seldom  pressed  upon  at  the  same 
time.  Lateral  movements  of  the  spine  are  apt  to  increase  a  root 
pain  on  the  opposite  side  and  to  lessen  a  root  pain  on  the  same  side 
to  which  the  spine  is  bent.  These  facts  probably  have  an  important 
bearing  upon  the  occurrence  of  rigidity  of  the  spine,  which  is  found 
in  patients  who  have  a  tumor  in  the  lower  dorsal  and  upper  lumbar 
regions  and  also  in  the  cervical  cord. 

In  general,  the  cervical  nerves  pass  outward  through  the  inter- 
vertebral foramina  at  almost  a  right  angle  to  the  long  axis  of  the 
cord;  the  loAver  the  level,  however,  the  more  is  the  downward  slope, 
so  that  the  fifth  lumbar  pair  emerge  six  vertebrse  lower  than  the 
level  of  their  origin.  The  lumbar  and  sacral  nerves  descend  in  al- 
most parallel  bundles  to  form  the  cauda  equina,  and  conceal  the 
delicate  filum  terminale.  The  arrangement  of  the  nerves  of  the 
Cauda  equina  is  such  that  the  outermost  bundles  correspond  to  the 
uppermost  nerves. 

The  relation  between  the  spines  of  the  vertebrae  and  the  sites  of 
origin  of  the  nerve  roots  from  the  cord  is  subject  to  considerable 
variation.     This  is  especially  the  case  in  the  thoracic  region,  where 


ANATOMV    OF    SPIXAI,    C'Ol.rMX    AND    COKD.  209 

some  oi  the  nerve  roots  show  variatious  in  their  site  oi"  origin  ex- 
lending  over  a  distance  covered  by  as  many  as  three  spinous  j)ro- 
•<^esses. 

THE  SPINAL  MEMBRANES. 

The  spinal  dura  mater  forms  a  loose  sheath  around  the  cord  and 
the  Cauda  equina  and  is  loosely  connected  l)y  areolai-  tissue  to  the 
periosteum  of  the  vertebrae.  On  each  side  are  the  double  openings 
for  the  roots  of  each  spinal  nerve,  a  tubular  prolongation  of  the 
dura  passing  over  the  nerves  for  a  short  distance.  In  contact  Avith 
the  smooth  inner  surface  of  the  dura,  but  not  adherent  to  it.  is  the 
arachnoid.  This  is  a  delicate  membrane  which  invests  the  cord, 
being  separated  from  it  by  considerable  fluid  in  the  subarachnoid 
space. 

In  addition  to  other  functions  the  fluid  acts  as  a  buffer  to  support 
the  spinal  cord  and  to  protect  it  from  injury. 

The  subarachnoid  space  is  incompletely  divided  into  anterior  and 
posterior  compartments  by  the  dentate  ligaments. 

The  pia  mater  is  intimately  adherent  to  the  cord  and  forms  its 
sheath  or  neurilemma.  Pia  mater,  arachnoid  and  dura  mater  are 
continuous  over  the  spinal  roots,  so  as  to  form  a  sheath  for  them 
as  they  pass  outward  to  the  intervertebral  foramina. 

From  each  lateral  surface  of  the  cord  a  narrow  fibrous  band,  the 
ligamentum  denticulatum  or  dentate  ligament,  extends  from  the 
pia  to  the  dura  throughout  the  entire  length  of  the  spinal  cord.  It 
separates  the  anterior  from  the  posterior  roots  and  contributes  to 
the  support  of  the  cord.  On  each  side  of  the  cord  the  ligament  ex- 
tends from  the  foramen  magnum  to  the  level  of  the  first  lumbar 
vertebra.  From  its  attachment  to  the  cord,  each  ligament  extends 
outward  and  is  attached  to  the  inner  surface  of  the  dura  l)y  numer- 
ous dentations  or  slips.  It  is  due  to  this  ligament  that  a  tumor  which 
^^ows  on  the  anterolateral  or  posterolateral  aspect  of  the  cord  may 
press  upon  only  anterior  or  posterior  roots  for  a  long  time,  and  thus 
give  only  anterior  or  posterior  root  symptoms  before  the  appearance 
of  symptoms  of  pressure  upon  the  cord  itself. 

The  dentate  ligament  ends  below,  at  the  level  of  the  first  lumbar 
vertebra,  in  a  fork-shaped  extremity.  The  outer  prong  of  the  fork  is 
usually  about  1  cm.  long,  and  is  attached  by  its  end  to  the  inner  sur- 
face of  the  dura.  Sometimes  this  prong  is  3  to  4  cm,  long.  The 
inner  prong  of  the  fork  is  attached  to  the  pia  on  the  lateral  aspect 
of  the  cord  and  is  ])rolonged  downward  along  the  side  of  the  con  us 
to  its  tip.  The  first  lumbar  posterior  root  rests  upon  this  fork  so 
that  the  "'  fork  "  may  be  used  as  an  anatomical  landmark  foi-  tlie 
13764—17 14 


210  WAR    SUEGERV    OF    THE    NERVOUS    SYSTEM. 

identificcitioii  of  the  fir^.t  liiiiibar  root.  I'he  posterior  roots  of  the 
lumbal'  and  sacral  nerves  are  dorsalJy  placed  with  reference  to  the 
fibrous  band  on  the  side  of  the  lumbosacral  cord  and  coiuis  deriv-ed 
from  the  dentate  ligament,  and  can  be  raised  up  on  a  probe.  At 
their  origin  from  the  lumbosacral  cord  the  ])osterior  roots  lie  close 
together,  but  Avhen  the,y  are  i-aised  up  with  a  probe  the  sepai-ate  lOots 
can  often  be  recognized.  If  one  liegiiis  to  connt  from  the  posterior 
root  which  lies  on  the  fork  of  the  dentate  ligament,  which  is  the  first 
lumbar,  one  can  often  identify  each  posterior  root. 

THE  RELATION  OF  THE  SEGMENTS  OF  THE  CORD  TO  THE 

VERTEBR.^:. 

The  relations  of  the  dilferent  segments  of  the  spinal  cord  and  of  the 
nerve  roots  to  the  spinous  pi'ocesses  of  the  A'crtebra'  can  be  ex[)ressed 
as  follows:  In  the  uppermost  cervical  region,  the  origin  of  the  nerve 
roots  from  the  cord  is  on  the  same  level  as  their  point  of  exit  from 
the  spinal  canal;  the  lower  the  nerve  root,  the  greater  the  distance 
betAveen  its  point  of  origin  from  the  cord  and  its  point  of  exit  from 
the  spinal  canal. 

In  general,  the  lov,er  boundary  of  the  cer\ical  cord  (the  level  of 
the  eighth  cervical  nerve)  corresponds  to  the  interspace  between  the 
fifth  and  sixth  cervical  spinous  ])rocesses ;  the  twelfth  dorsal  segment 
lies  about  opposite  the  ninth  dorsal  spine;  the  fiftli  lumbar  segment 
corresponds  to  the  twelfth  dorsal  spine.  The  segments  of  the  spinal 
cord,  therefore,  lie  on  a  higher  level  than  the  corresponding  vertebrae. 
The  fourth  cervical  segment  lies  about  opposite  the  third  cervical 
spine ;  the  fourth  dorsal  opposite  the  second  dorsal  spine ;  the  eighth 
dorsal  opposite  the  fifth  dorsal  spine ;  the  twelfth  dorsal  of)posite  the 
ninth  dorsal  spine;  the  second  lumbar  on  the  level  of  the  tenth  dorsal 
spine;  the  sacral  segments  opposite  the  twelfth  dorsal  and  first  lum- 
bar spines.  It  must  be  well  understood  that  the  lower  the  level  of  the 
segment  in  {]uestion,  the  greater  the  distance  between  it  and  the 
correspondingly  named  spinous  process. 

THE  BLOOD  VESSELS  AND  THE  MAIN  FIBER  TRACTS  OF  THE  CORD. 

A  superficial  account  of  the  anatomy  of  the  spinal  cord  and  the 
cou.rse  of  its  conducting  fibers  woidd  carr}'  me  far  beyond  the  bounds 
of  what  is  necessary  in  this  volume.  Presupposing,  therefore,  that 
the  reader  has  a  good  knowledge  of  this  subject  or  will  obtain  de- 
tailed infoi-mation  from  larger  textbooks  of  anatomy  and  physiology, 
T  shall  mention  only  a  few  facts  of  practical  importance. 

The  spinal  cord  is  incompletely  divided  into  two  Imhes  by  the 
fissures  wdiich  pass  in  from  the  anterioi-  and  posterior  surfaces  of  the 


AXAI()M\     OK    SPINAL    COI.rMX    AXI)    C'f)RD.  211 

cord.  The  unterior  fissure  is  wider  and  shorter  than  the  posterior 
one  and  reaches  to  the  white  commissure.  It  contsiins  a  fohl  of  pia 
mater  and  many  blood  vessels.  The  posterior  fissure  or  septum  also 
.serves  to  conduct  blood  vessels  to  the  substance  of  the  cord.  When 
an  incision  is  made  in  this  septum,  considei-able  oox.inj>-  of  lilood  is 
apt  to  occur,  and  therefore  it  is  advisable  to  make  the  incision  rather 
a  little  to  one  side  of  the  septum.  There  ai-e  shallow  furrows  on  each 
side  of  the  cord  in  front  and  behind,  corresponding  to  the  lines  of 
attachment  of  the  anterior  and  posterior  roots.  Othei-  grooves  mark 
off  the  mediodorsal  or  Goll's  column  and  the  laterodorsaj  f»r  Bur- 
dach's  column.  Tiie  gni.V  matter  occupies  the  more  central  parts  of 
the  cord,  and  appears  in  the  form  of  two  irregidarly  ci-escentic  por- 
tions on  each  side  united  across  the  median  line  by  the  gray  com- 
missure. 

The  blood  supply  of  the  spinal  cord  is  deri\ed  from  the  anterior 
and  posterior  spinal  artei'ies — branches  of  the  \  ertei)ral  arteries.  The 
posterior  spinal  vessels  ai'e  of  special  importance  because  they  are 
the  ones  that  are  most  often  injured  in  spinal  fi'actures.  and  because 
of  their  position  on  the  posterior  aspect  of  the  cord  they  are  in  the 
operative  tield  during  laminectomy.  The  posterior  spinal  arteries 
run  down  on  each  side  of  the  posterior  surface  of  the  cord  in  fr(mt 
of  the  origins  of  the  ]wsterior  nerve  roots.  They  are  more  or  less 
tortuous  and  give  off  i»umerous  branches  which  perforate  the  cord 
and  the  posterior  median  septum.  Branches  of  the  posterior  spinal 
veins  form  a  free  anastomosis  around  the  dorsal  roots  of  the  spinal 
nerves  and  acc(unpany  each  posterior  root  through  the  opening  in  the 
dura.  These  branches  are  sometimes  much  enlarged  so  that  they 
cause  undue  pressure  upon  the  nerve  roots  and  cause  root  pains. 
Branches  of  the  two  posterior  spinal  arteries  anastomose  with  each 
other  so  that  the  vessels  may  be  considered  as  a  series  of  communi- 
cating loops. 

The  spinal  conducting  paths  are  either  exogenous,  which  originate 
in  cells  outside  of  the  cord,  or  endogenous,  which  originate  from  cells 
within  the  cord  substance. 


212 


WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 


The  exogenous  fibers  are  either  centrifugal  or  centripetal.     The 
rnain  fiber  tracts  are  the  following : 

A.  I.  CENTRIFUGAL   OR    DESCENDING  (MODIFIED    FROM   BING). 


Name. 

Origin. 

Course. 

Ending. 

1.  Corticospinal  or  pyram- 

idal: 
(a)  Direct. 
(6)  Lateral. 

2.  Subcorticospinal: 

(a)  Rubrospinal 

(Monakow's 
bundle;. 

(b)  Thalamospinal.. 

(c)  Tectospinal 

(d)  Vestibulospinal. 

Motor  cortex  of  brain.  . 

(o)  In  anterior  columns 

(ft)  In  lateral  columns  after 
decussating  in  medulla. 

In    lateral    columns    after 
crossing. 

In  lateral  columns  with 
rubrospinal  tract  after 
crossing. 

do 

In    cells    of    anterior 
horns. 

Do. 

Optic  thalamus 

Do. 
Do. 

Deiter's  nucleus 

In  anterior  columns  without 
crossing. 

Do. 

II.  CENTRIPETAL   OR  ASCENDING., 


1.  Short  fibers  from  poste- 

rior  roots. 

2.  Long  fibers  from  poste- 

rior roots. 

3.  Long  fibers 

Spinal   ganglia   from 

periphery. 
.     .  do  

Through  marginal  zone 

Through     posterior    horns 

without  crossing. 
Through  posterior  columns. . 

In  cells  of  anterior  and 

posterior  horns. 
In  Clarke's  columns. 

do          

In    nuclei    of    poste- 

rior    columns     and 
medulla. 

B.  I.  ENDOGENOUS   FIBERS. 


1.  Spinocerebellar: 

(a)  Dorsal  (Flechsig) 

(6)  Ventral  (Gower's) 


(c)  Spinothalamic. 

2.  Association  tracts: 

(a)  In  anterior  col- 
umns. 

(6)  In  posterior  col- 
umns. 

3.  Boot  fibers 


Cells  of  Clarke's  col- 
umn. 
Cells  of  anterior  horn. , 


Cells  of  posterior  horn . 


Cells  of  anterior  horn. 


Lateral  column  without 
crossing. 

Anterior  part  of  lateral  col- 
umn partly  crossed,  partly 
uncrossed. 

In  lateral  column  after  cross- 
ing. 


Peripheral  nerves. 


Incerebellum  (vermis). 
Do. 


In  optic  thalamus . 


Part  2. 

THE  NORMAL  AND  PATHOLOGICAL  PHYSIOLOGY  OF  THE 

SPINAL  CORD. 

The  spinal  cord  is  a  sensor.y,  motor,  vasomotor,  and  trophic  organ. 

1.  It  contains  fil>ers  for  the  transmission  of  various  kinds  of  sensa- 
tion— tactile,  temperature,  pain,  deep  muscle,  and  joint  sense.  The 
fibers  for  touch  enter  the  cord  in  the  posterior  roots  and  pass  upward 
in  the  posterior  columns  parth^  on  the  same  and  partly  on  the  oppo- 
site side.  The  fibers  from  each  root  lie  outside  and  somewhat  super- 
ficial to  those  from  the  next  lower  root.  They  thus  form  a  series  of 
lamellar  tracts,  the  fibers  from  each  posterior  root  as  they  enter  the 
posterior  columns  crowding  the  fibers  from  the  next  lower  nerve  root 
more  toward  the  median  line.  P'rom  this  it  residts  that  the  fibers 
for  tactile  sensation  from  the  lumbar  and  sacral  nerves  lie  nearest 
the  median  line,  the  dorsal  more  external  and  posterior,  and  so  on. 
When  one  j)art  of  the  sensory  jjathway  in  the  cord  is  interrupted 
other  tracts  may  take  up  the  transmission  of  sensations.  Although 
this  is  probably  true  for  all  kinds  of  sensation,  the  tactile  sensations 
especially  seem  to  run  in  a  bilateral  path  and  are  not  so  apt  to  be 
markedly  affected  by  a  purely  unilateral  lesion. 

The  fibers  for  temperature  and  pain  sensation  enter  in  the  pos- 
terior roots,  soon  pass  into  the  gray  matter  of  the  posterior  horns, 
and  crossing  over  to  the  other  side  enter  the  anterioi-  part  of  the 
lateral  columns  and  run  upward  to  the  optic  thalami.  The  fibers 
for  the  sensations  of  temperature  do  not  cross  t6  the  other  side  as 
quickly  as  the  fibers  for  pain,  but  require  from  two  to  five  segments 
for  their  complete  crossing. 

The  fibers  for  deep  muscle  sense  (postural  recognition,  spacial  dis- 
crimination— bathyesthesia  of  Oppenheim)  in  part  pass  up  in  the 
posterioj'  columns;  in  part  they  enter  the  posterior  horns,  pass  out- 
ward and  then  upward  in  the  posterior  parts  of  the  lateral  columns 
(latei-al  cerebellar  tracts)  to  end  in  the  cerebellum. 

2.  The  pyramidal  tracts,  lying  in  the  lateral  and  in  the  mesial 
l^arts  of  the  anterior  columns,  contain  the  main  fibers  for  the  trans- 
mission of  motor  impulses  to  the  muscles  through  the  anterior  roots. 
Interference  with  these  tracts  is  not  always  followed  by  a  complete 
paralysis,  because  there  are  a  number  of  secondary  tracts  w^hich 
contain   fibers  from   lower  centers  to  the  motor  nerve  cells  in  the 

213 


214  WAR    SUK(:iERY    OF    THE    NERVOUS    SYSTEM. 

anterior  horns  wliicli  can  to  a  certain  extent  take  up  the  functions 
of  the  pyramidal  tract  fibers.  Whih'  destruction  of  the  pvrauiidal 
tracts  may  n(  t  cause  a  c()m])lete  paralysis,  the  destruction  of  the 
cells  in  the  anterioi-  horns  (which  are  secondary  <-«'ut(ns  fcr  the 
muscles  of  the  trunk  and  extremities)  will  be  followed  by  a  com- 
plete paralysis  and  atrophy  of  the  muscles  innervated  from  these 
cells.  Muscle  tone  and  the  muscle  and  tendon  reflexes  are  controlled 
through  the  pyramidal  tracts  and  the  anterior  spinal  roots.  Muscle 
tone  is  controlled  through  the  cells  in  the  anterior  gray  horns,  but 
these  are  under  the  influence  of  sensory  stimuli  which  are  continually 
passing  to  the  cells  from  the  periphery,  both  from  the  skin  and  from 
the  muscles  themselves.  The  tone  of  the  muscles  would  be  too  great 
and  the  reflexes  too  active  if  it  were  not  for  controlling  and  regu- 
lating influences  from  higher  centers  which  pass  down  to  the  cells 
in  the  anterior  horns  through  the  fibers  in  the  pyramidal  tracts. 
These  considerations  explain  why  a  lesion  of  the  pyramidal  tracts  is 
followed  by  hypertonus  and  an  exaggeration  of  tendon  reflexes,  a 
lesion  of  the  anterior  spinal  roots  by  a  loss,  and  lesion  of  posterior 
spinal  roots  or  posterior  white  columns  by  a  more  or  less  well-marked 
diminution  in  muscle  tone  and  in  the  tendon  reflexes. 

3.  The  cells  in  the  gray  horns  form  the  trophic  centers  for  the 
motor  nerve  fibers  which  originate  from  them.  Destruction  of  the 
cells  in  the  anterior  horns  is  followed  by  a  typical  Wallerian  degener- 
ation in  the  nerve  fibers  from  these  cells,  followed  by  a  degener- 
ative atrophy  of  the  muscles,  so  that  they  no  longer  respond  in  the 
normal  manner  to  the  electrical  current.  The  typical  "  reaction  of 
degeneration  "  consists  of  ( 1 )  a  loss  of  contractility  of  the  muscles 
when  the  nerves  are  stimulated  by  either  the  faradic  or  galvanic  cur- 
rent, and  (2)  a  loss  of  faradic  contractilit}''  and  an  increased  irrita- 
bility to  galvanism. of  the  muscles  themselves.  When  complete  de- 
generative atrophy  has  occurred  neither  nerve  nor  muscle  will  re- 
spond to  faradic  or  galvanic  stimulation.  The  sensory  nerves  which 
are  continued  as  the  posterior  spinal  roots  will  similarly  degenerate 
when  they  are  separated  from  the  spinal  ganglia,  which  are  the 
trophic  centers  for  the  peripheral  sensory  nerves.  The  central  nerv- 
ous system  exercises  a  trophic  influence  upon  all  of  the  tissues  of  the 
hodij,  upon  the  muscles  and  bones,  as  well  as  the  skin  and  its  adnexa. 
There  is  no  satisfactory  evidence  that  there  are  special  trophic  nerves, 
and  most  investigators  of  this  subject  have  concluded  that  in  a  way 
not  yet  understood  the  central  nervous  system — ^brain  and  spinal 
cord — exerts  this  trophic  influence, 

4.  The  spinal  cord  also  exercises  a  control  over  the  ^"asonlotor  sys- 
tem. Lesions  of  the  cord  may  result  in  either  increased  redness  and 
heat  of  the  skin  with  hyperidrosis,  or  in  cyanosis  or  pallor,  fall  in 


PHVtilOIXKU    OF    SPINAJ.    CORD.  215 

cutaneous  temperature  and  anidiosis.  As  far  as  is  known,  the  vaso- 
motor centers  lie  in  the  anterior  gray  iiorns  of  tlie  spinal  cord. 

From  what  has  been  stated  above,  we  can  in  a  general  way  under- 
stand the  symptoms  which  will  arise  from  disease  or  destruction  of 
fibers  or  cells  in  the  cord.  We  must  next  determine  wliat  are  the 
functions  of  the  diiferent  parts  of  tlie  cord  and  of  the  nerve  roots, 
and  what  symjitoms  follow  the  division  of  ner\  e  roots  or  cord  tracts. 

The  functions  of  the  spinal  roots. — Irritation  of  a  posterior  or  sensory 
spinal  root  will  cause  pain,  hyperesthesia  or  paresthesia  over  part  or 
the  entire  area  of  distribution  of  the  nerAe  root.  Disease  or  pres- 
sure may  affect  only  a  few  of  the  bundles  that  make  up  a  posterior 
root;  this  will  occur  most  often  in  the  cervical  region  where  the 
nerve  bundles  originate  over  a  considerable  length  of  the  cord  and 
unite  only  at  the  clural  opening. 

If  the  entire  nei'\'e  root  is  desi  roved,  tliei'e  may  be  some  sensory 
disturbances  (hypesthesia ).  Acccrding  to  the  so-calletl  ''Sherring- 
ton's law."  each  area  or  Jcoric  of  the  skin  is  supplied  by  three  .spinal 
roots  and  anesthesia  will  occiii'  only  when  three  successive  roots 
have  been  destroyed.  In  these  cases  all  kinds  of  sensatiisn — tactile, 
pain,  thermal,  deep  muscle — -are  lost. 

I)i\'isi()n  of  a  number  of  jiostcrior  loots  from  an  exti'emity  will 
cause  a  marked  atony  and  ataxia  of  the  limb.  This  is  due  both  to  the 
loss  of  deep  muscle  sense  and  to  tlie  destruction  of  the  afferent  part 
of  tlie  reflex  arcs  which  control  the  toiu^  of  the  muscles. 

As  will  be  shown  in  the  chajiter  on  sjunal  localization,  root  ])ains 
and  I'oot  anesthesias  a?e  im^tortant  in  tlie  localization  of  the  level  of 
a  spinal  lesion. 

In  the  case  of  the  aniev'ior  roots,  the  question  is  a  more  simple 
one.  Irritation  (if  an  anterior  root  will  be  folloAved  by  muscle  spasm 
or  hypertonicity ;  division  of  one  or  more  roots  will  be  follovyed  by 
weakness  and  loss  of  tone  or  paralysis  of  the  muscle  or  muscles  inner- 
vated by  the  root,  folloA\ed  sooner  or  later  by  atrophy  of  the  muscles. 

Eesults  of  lesions  of  the  central  gray  matter. — In  these  cases  the 
sensory  symptoms  are  generally  of  the  nature  known  as  dissociated, 
i.  e.,  there  is  a  disturbance  in  the  thermal  and  pain  senses  with  per- 
sistence of  normal  or  almost  normal  tactile  sense.  The  disturbance 
in  thermal  sensation  is  usually  incomplete  imless  parts  of  the  lateral 
white  columns  are  also  afi'ected.  and  waim  is  somtimes  better  felt  than 
cold,  or  vice  versa.  At  othei'  times  there  may  be  a  perversion  of  tlie 
temperature  sense,  so  that  cold  is  felt  as  warm,  and  warm  as  cold. 
The  sensory  disturbance  may  occur  over  large  or  small  areas. 

The  motor  symptoms  consist  of  weakness  or  paralysis  of  the  mus- 
cles whose  centers  lie  within  the  affected  ai-ea,  followed  by  rapid 
degenerative  atrophy. 


216  WAR    SURGERY    OF    THE    NERVOUS    SYSTEM. 

Division  of  the  posterior  white  columns. — If  the  posterior  Avbite  col- 
umn of  one  side  alone  is  divided,  there  is  no  sensory  disturbance 
at  all  or  only  some  diminution  of  deep  muscle  sensibility  on  the  same 
side.  If  both  posterior  columns  are  divided,  there  will  be  a  diminu- 
tion or  loss  of  tactile  and  deep  muscle  sensation  below  the  level  of 
the  lesion.  In  unilateral  division  of  the  posterior  column  there  may 
also  be  slight  disturbance  in  pain  and  thermal  sensibility  on  the  side 
opposite  to  the  lesion,  if  the  marginal  root  area  has  been  injured 
(injury  to  root  fibers  in  the  marginal  root  zone). 

Division  of  a  lateral  white  column  will  cause  a  paresis  or  paralysis  of 
all  the  muscles  supplied  below  the  level  of  the  lesion  on  the  same 
side,  associated  with  a  marked  increase  of  tone  of  the  muscles  (spas- 
ticity) and  an  increase  of  muscle  and  tendon  reflexes.  Vasomotor 
disturbances  are  sometimes  observed.  The  sensory  changes  affect  the 
thermal  and  pain  senses  on  the  opposite  side.  Homolateral  and 
contralateral  ataxia  have  also  been  observed. 

Division  of  one-half  (hemisection)  of  the  cord. — The  symptoms  which 
follow  ])resent  a  well-recognized  picture  known  as  the  Brown - 
Sequard  syndrome,  from  the  author,  who  was  the  first  to  make  a 
careful  study  of  the  symptoms.  In  the  tj^pical  cases  there  are  motor 
paral3^sis,  superficial  hyperesthesia,  loss  of  deep  muscle  sense  and 
vasomotor  disturbances  on  the  side  of  the  lesion,  and  loss  of  tactile,^ 
pain,  and  temperature  sense  on  the  opposite  side. 

Complete  transverse  division  of  the  cord  is  followed  by  a  loss  of  all 
motor  and  sensory  power  below  the  level  of  the  lesion,  with  loss  of 
superficial  and  deep  reflexes  and  paralysis  of  the  bladder  and  rectum. 
Occasionally,  slight  reflexes  will  persist  for  a  short  time,  but  in  the 
majority  of  instances  the  loss  is  immediate  and  complete.  The  symp- 
toms of  an  incomplete  transverse  lesion  of  the  cord  will  be  considered 
in  another  chapter. 

THE  SENSITIVENESS  OF  THE  CORD  AND  MEMBRANES. 

Although  our  knowledge  of  this  subject  is  still  meager,  investi- 
gations I  have  made,  which  substantiate  the  results  of  others,  have 
led  me  to  the  following  conclusions :  The  outer  surface  of  the  dura 
is  insensitive,  while  its  inner  surface  is  very  sensitive.  When  the 
inner  surface  of  the  dura  is  scratched  or  rubbed,  a  distinct  pain 
I'cferred  to  the  back  is  complained  of  by  the  patient.  The  pia  arach- 
uoid  and  the  dentate  ligament  are  not  sensitive.  A  sli])  of  the  liga- 
ment may  be  grasped  with  a  forceps  and  divided  with  scissors  with- 
out pain.  f 

The  cord  tissue  itself  is  not  sensitiAe  to  pain,  as  far  as  I  ha^e  been 
able  to  determine  during  my  operations  under  local  anesthesia  and 


PHYSIOLOGY    OF    SPINAL    COBD.  217 

in  experiments  on  aniniiils.  AA^hen  an  incision  is  njade  in  the  poste- 
rior colnmns  neni-  the  origin  of  the  posterioi-  roots,  however,  the 
patient  will  comphiin  of  a  peculiar  burning  pain  which  may  be 
referred  to  an  extremity,  although  often  the  patient  will  declare 
that  he  feels  pain  but  is  unable  to  localize  it. 

The  posterior  spinal  roots  are  very  sensitive  in  their  entire  course, 
the  painful  sensations  being  referred  to  the  periphery.  In  one  or 
two  instances  I  have  gained  the  impression  that  the  anterior  nerve 
roots  were  not  entirely  insensitive,  but  I  am  in  some  doubt  as  to  the 
correctness  of  these  observations. 


Part  3. 

THE  LOCALIZATION  OF  MOTOR,  SENSORY,  AND  REFLEX 
FUNCTIONS  IN  THE  DIFFERENT  SEGMENTS  OF  THE 
SPINAL  CORD. 

The  sj)inal  centers  for  the  muscles  of  the  trunk  and  extremities  lie 
in  the  cells  of  the  gray  matter  of  the  cord.  Most  of  the  muscles  have 
a  plurisegmental  innervation  and  there  is  no  evidence  that,  as  in  the 
brain,  distinct  nuclei  for  single  muscles  or  even  for  muscle  groups 
exist. 

With  few  exceptions  the  muscles  are  innervated  from  groups  of 
cells  which  extend  over  several  segments.  Muscles  with  different 
functions  may  be  innervated  through  the  same  anterior  root  (Forgue 
and  Lannegrace,  Martin,  Sherrington).  According  to  Herringham, 
of  two  muscles,  both  of  which  receive  their  nerve  supply  from  cells 
in  several  segments,  the  one  nearer  the  head,  the  one  nearer  the  long 
axis  of  the  body,  or  the  one  of  the  two  that  is  more  superficially 
placed  will  be  supplied  by  the  uppermost  of  the  segments  in  question. 

If  the  general  facts  just  given  be  kept  in  mind,  the  localization  of 
the  centers  for  the  muscles  will  be  easily  understood.  The  following 
table  has  been  modified  from  that  of  Flatau  (Handbuch  der  Neuro- 
logic, Vol.  I,  Part  II,  pp.  659  to  661),  to  which  I  have  added  the 
main  function  of  each  muscle  or  muscle  group. 

THE  SEGMENTAEY  LOCALIZATION  OF  THE  MUSCLES. 

A.  Muscles  of  the  head  and  trunk. 

/.  Muscles  of  the  back. 
Trapezius C  2-4 Rotation   of    scapula,  raises  shoulder, 

moves  head  to  side. 
Latissimus  dorsi C  6-8 Adducts  and  ro  tates  arm  inward,  draws 

arm  backward,  raises  ribs. 

Rhomboid C  4-5 Rotates  and  moves  scapula  backward. 

Levator  anguli  scapula? .C  3-5 Raises  angle  of  scapula. 

Serratus  posticus  superior D  1-4 Respiration. 

Splenius  capitis C  2-8  (?) Rotates  head  and  draws  it  to  side. 

Paravertebral  muscles C  1-S  3 Movements  of  vertebral  column. 

Rectus  capitis  major C  1-2 ^^^^^^^  ^^^^  ^^^^  ^^^^^.  .^  ^^^^ 

Rectus  capitis  minor CI J 

Obliquus  capitis  superior C  1 jj^^,^,^  ,^^^^  ^^^^  ^^^^,  j^  ^^^^ 

Obliquus  capitis  inferior 0  2 i 

II.  Muscles  of  neck,  chest,  and  abdomen. 
Muscles  of  the  neck: 

Platysma 0  3 Depresses  lower  lip  and  angle  of  month, 

wrinkles  skin  of  neck. 
Sterno-mustoid C  2-3 Rotates  and  draws  head  to  shoulder, 

muscle  of  inspiration. 

218 


Consliicl  cavity  of  abdomen,  assist  ex- 
piration, rotate  trunk,  move  jjelvis. 


I.OCArJZATION    OF    FUNCTIONS.  219 

A.  Muscles  of  the  head  and  trunk — Contiaued. 

//.  Muscles  of  neck,  chest,  and  abdomen — Continuert. 
Muscles  ol'  the  neck  -Continued. 

Sterno-liyoid C  W.i I 

Omo-hyoid C  1-3 |  Depress  larynx  and  hyoid  bone,  contrcM 

Steruo-thyroid C  1-4 |     movements  of  thyroid  cartilage. 

Thyro-hyoid C  1-2 I 

Longus  colli C  2-8 iFlex  an<l  rotate  cervical  vertebral  col- 

Lougus  capitis C  1-4. J     umu. 

Rectus  capitis  anticus CI Kle>;es  and  roiale.s  head. 

Scalenus  auticus C  4-7 i 

Scalenus  medius C  2-8 Raisf  ribs  for  inspiration. 

Scalenus  post  icus ( '  .5-8 I 

Muscles  of  the  chest: 

Pecloralis  major ('  .5-(i \Addaclion,    downwar  I    ami     forward 

Peetoralis  minor C  7-8  (Bl) '     movement  of  arm. 

Subclavius 0  5-0 Depres.ses  shoulder. 

Sen-atu.s  anticus C  5-7 Fixes  scapula. 

l.evatores  cost  arum C  8-7)  11 Fix  ribs. 

Intercostals C  2-11 Inspiration. 

Triangularis  st erni D  3-4 Expiration. 

Diaphragm C  3-5 Respiration. 

Muscles  of  abdomen: 

Rectus  abdominis D  .5-12 

Pyramidalis D  12-L  1 

Obliquus  externus D  5-12 

Obliquus  internus D  8-L  1 

Transversalis D  7-L  1 

Quadratus  himborum D  U-L  or  L  1-4 Moves  pelvis  and  trunk,  inspiration. 

Coccygeus S  ;-i-5,  C Supports  coccyx. 

B.  Muscles  of  the  extremities. 

/.  Muscles  of  the  uppir  crtremilUs. 
(a)  Shoulder: 

Deltoid C  .5-0 

Supraspinatus ...05 

Infraspinatus .0  5-6 

Teres  minor C  5 Rotates  arm  outward. 

Teres  major C  (5),  6,  (7) Rotates  arm  inward. 

Subscapularis C  5-6 Rotates  arm  inward. 

(6)  Arm: 

Biceps C  5-6 Flexes  and  supinaies  forearm. 

Coraco-brachialis C  6-7.. Adducts  forearm. 

Brachialis  anticus C  5-6 Flexes  forearm. 

Triceps C  6-7  (8) Extends  forearm. 

Subanconeus C  7  (8) Fixation  of  synovial  membrane. 

(c)  Forearm: 

Pronator  radii  teres C  6-7 Pronates  forearm. 

Flexor  carpi  radialis C  6-7 Flexes  and  radially  flexes  hand. 

Palmaris  longus C  (7),  8,  (D  1) Flexes  hand. 

Flexor  carpi  ulnaris C  (7),  8,  (D  1) Flexes  and  ulnar  flexes  hand. 

Flexor  sublimis  digitorum..C  7-8,  D  1) Flexes  middle  phalanges,  2-5  fingers. 

Flexor  profundus  digitorumC  7-8,  D  1 Flexes  last  phalanges,  2-5  fingers. 

Flexor  longus  pollicis C  6-7 Flexes  last  phalanx  of  thumb. 

Pronator  q  uadratus C  6-8,  D  1 Pronates  forearm . 

Supinator  longus C  5-6 Flexes  forearm. 

Extensor  carpi  radialis 0  (5),  6-7 Extends  radially,  flexes  hand. 

Extensor    communis    digi- 
torum C  6-8 E.xtensiou  of  first  xihalauges,  2-5  fingers. 

Extensor  minimi  digiti C  (6),  7-8 Extension    of    first    phalanx    of    little 

finger. 

Extensor  carpi  ulnaris C  (6),  7-8 Extension  and  ulnar  flexion  of  hand. 

Supinator  brevis C  5-7 Supinates  forearm. 

Abductor  longus  pollicis. .  .0  6-7 Abducts  first  metacarpal. 

E.xten.sor  brevis  pollicis C  6-7 Extension  of  first  phalanx  of  thimib. 

Extensor  longus  policis C  6-7,  (8) Abducts  first  metacarpal:  extension  of 

last  T)halanx  of  thumb. 

Extensor  propriusindicis.  .C  6-8 Extension  of  first  phalanx   of  index- 
finger. 


|.-\bducl  arm  lo  horizontal,  abduct  and 
I    rotate  arm  outward. 


'  >External  rotation  of  thigh. 


[•Extension  of  leg. 


220  WAR    SURGERY    OF    THE    NERVOUS   SYSTEM. 

B.  Muscles  of  the  extremities — Continued. 
/.   Muscles  of  the  upper  extremities — Continued. 
(d)  Hand: 

Al^ductor  brevis  pollicis C  6-7 A  bducts  first  metacarpal. 

Flexor  brevis  pollicis C  6-7 Flexes  first  phalanx  of  thumb. 

Opponens  pollicis C  6-7 Opposition  of  first  metacarpal. 

.Vdductor  pollicis C  6-7 Addncts  first  metacarpal. 

-Vbductor  minimi  digiti C  S,  D  1 Abdncts  little  finger. 

Flexor  brevis  minimi  digiti. C  (7),  8,  (D  1) Abducts  and  flexes  little  finger. 

Opponens  minimi  digiti C  (7),  8,  (D  1) Draws  forward  5th  metacarpal. 

Lumbricales C  7-8,  (D  1) Abduct  and  adduct  fingers. 

Interossei C  7-8.  (Dl) Extension  of  2d  and  .3d  phalanges. 

If.  Muscles  of  the  lower  extremities. 

(a)  Hip: 

Hiacus L  2-4 Flexion  at  hip. 

Psoasmajor (D  12),  L  1-3,  (4)..-)  „,     .        ,,. 

13            ■  /T^  io    T  1  Q  )/^     ^Flexion  at  hip. 

Psoas  minor (D  12),  L  1-3,  (4).. J 

Gluteus  maximus (L  4).  .5,  S  1,  (2) Extension  of  thigh. 

Tensor  fasciae  lata? L  4-5 Flexion  of  thigh. 

Gluteus  raedius I-  4-5,  S  1 ■)  Abduction    and    internal    rotation     of 

Gluteus  minimus L  4-5,  SI '    thigh. 

Pyriformis S  1-2 External  rotation  of  thigh. 

Obturator  internus L  5,  S  1-2. . . 

Quadratus  feinoris L  4-5,  SI... 

(b)  Thigh: 

Sartorius L  2-3 Internal  rotation  of  leg. 

Rectus  fenioris L  2-4 1 

Vastus  medius L  2-3 

Vastus  internus L  2-4 

Vastus  externus L  3-4 

Pectineus L  2-3 

.Adductor  longus L  2-3 

Gracilis L  2-4 Adduct  thigh. 

.Adductor  brevis L  2-4 

Adductor  magnus L  3-4 

Obturator  externus L  3-4 Adduction    and    external    rotation    of 

thigh. 

Biceps L(4),  5,  S  1-2 1 

Semitendinosus L  4-5,  S  1 JFlex  leg. 

Semimembranosus L  4-5,  S  1 1 

(c)  Leg: 

Tibialis  anticus L  4 ,  (5) Dorsal  flexion  and  supination  of  foot. 

Extensor  longus  digitorum.L  4-5,  S  1 Extension  of  toes. 

Peroneus  tertius L  5,  (S  1) Dorsal  flexion  and  pronation  of  foot . 

Extensor  longus  pollicis L  4-5  (S  1) Extension  of  large  toe. 

Peroneus  longus L  5,  S  1 1^-.       ^a     ■  j  <.•        r  <•    * 

,     "  .                       ^       „  ,  >Dorsal  flexion  and  pronation  of  foot. 

Peroneus  brevis L  o,  S  1 > 

Gastrocnemius L  (4),  5,  S  1-2 1 

Soleus L  (4),  5,  SI,  (2)...  Plantar  flexion  of  foot. 

Plantaris ( L  4-5,  S  1) J 

Popliteus L4-5,  S  1 Flexion  of  leg. 

Tibialis  posticus L  5,  S  1,  (2) Adduction  of  foot. 

Flexor  longus  digitorum . .  .L  5,  S  1-2 Flexion  of  last  phalanges  II  toJV. 

Flexor  longus  pollicis   . L  5,  S  1-2 Flexion  of  last  phalanx  of  large  toe. 

(d)  Foot: 

Extensor  brevis  pollicis L  4-5,  (S  1) Extension  of  large  toe. 

Extensor  brevis  digitorum. .L  4-5,  S  1 Extension  of  toes. 

Abductor  pollicis L  5-S  1 

Flexor  lirev  is  pollicis. . . L  5-S  1 

.\dductor  pollicis S  1-2 

Abductor  minimi  digiti S  1-2 

Opponens  minimi  digiti S  1-2 

Flexor  brevis  digitorum L  5-S  2 

lyumbrieales S  1-2 

Interossei S  1-2 


Movement  of  toes. 


LOCALIZATION    OF    FUNCTIONS. 


221 


THE    SPXJMEiNT    DI8TKIBUTIGN    Ol'    SENSATION    IN    THE    BODY. 

Aiiatoniical,  physiological,  and  experimental  investigations  have 
led  to  the  division  of  the  skin  of  the  body  into  a  number  of  areas  or 
zones  (Head,  Thorburn,  Starr,  Mackenzie,  Petrien.  Sherren.  etc.)  in 
relation  to  the  different  spinal  segments.  These  areas  are  not  distinct 
but  overlap  each  other,  so  that  each  area  is  supplied  from  three 
spinal  segments  (Sherrington).  This  o\'erlapping  does  not  occur 
to  the  same  extent  in  all  parts  of  the  bod}'^ ;  on  the  chest  and  abdomen 
the  zones  overlap  each  other  only  partially  while  in  tiie  hand,  for 
example,  each  area  of  skin  is  supplied  by  three  spinal  roots.  It  is 
of  some  practical  importance  to  remembei'  that  the  ovei'lapping  foi- 
the  sensation  of  pain  is  alwaj^s  less  than  that  for  touch. 

Notwithstanding  the  large  amount  of  investigation  that  has  been 
made,  the  exact  size  and  shape  of  the  areas  supplied  by  the  several 
spinal  roots  have  not  been  determined  Avith  certainty,  l^robably 
considerable  variations  occur  in  different  individuals. 

4.  In  addition  to  these  reflexes,  the  folloM^ing  centers  must  be  men- 
tioned : 

1.  The  cilio  spinal  (.-enter C  8  to  D  1 

2.  The  center  for  the  bladder S  3-4 

3.  The  center  for  the  rectum S  3-4 

4.  The  center  for  the  sexual  organs S  2-3 

5.  The  spinal  respiratory  center  (phrenic  nerve) C  3-.^» 


THE   CENTERS    FOR    THE    SKIN   AND    TENDON    REFLEXES    IN    THE    SPINAL    CORD 

(ACCORDING  TO   BING). 


Tendon  reflex. 


Biceps  reflex 

Triceps  reflex 

Scapulo  -  h  u  m  e  r  a  1 

reflex. 
Radius  reflex 


Skin  reflex. 


Scapula  reflex. 


Elicited  by- 


Palmar  reflex 

Epigastric  reflex . . 

Upper  abdominal 

reflex. 
Lower  abdominal 

reflex. 
Cremaster  reflex. . 


Patellar  reflex. 


Gluteal  reflex. 


Achilles  reflex. 


Plantar  reflex. 
.\na]  reflex 


Irritation  of  skin  over 
scapula. 

Blow  on  tendon  of  biceps . . 

Blow  on  tendon  of  triceps. 

Blow  on  lower  inner  angle 
of  scapula. 

Blow  on  styloid  process  of 
radius. 

Irritation  of  palm  of  hand. 

Irritation  of  lower  part  of 
chest. 

Irritation  of  skin  over  up- 
per abdomen. 

Irritation  of  skin  of  lower 
abdomen . 

Irritation  of  region  over 
adductor  muscles. 

Blow  on  tendon  of  quad- 
riceps. 

Imtation  of  skin  of  gluteal 
region. 

Blow  on  Achilles  tendon. . 

Irritation  of  skin  of  sole . . . 

Pricking  of  perineum 


Result. 


Contraction  of  muscles 
of  shoulder  blade. 

Flexion  of  forearm 

Extension  of  forearm 

Adduction  of  arm 

Supination  of  forearm . . . 

Flexion  of  fingers 

Contraction  in  epigastric 
region. 

Contraction  of  abdomi- 
nal muscles. 

do 

Elevation  of  testis 

Extension  of  leg 

Contraction    of   gluteal 

muscles. 

Extension  of  foot 

Flexion  of  toes 

Contraction  of  sphincter 

ani. 


Localiza- 
tion. 


C5-D1. 

C5-6. 
C6-7. 
C6-7. 

C7-8. 

C&-D  1. 
D7-9. 

D8-9. 

D  10-12. 

L  1-2. 

L2-4. 

L4-5. 

S  1-2. 
S  1-2. 

8  5. 


Part  4. 
THE  SYMPTOMATOLOGY  OF  SPINAL  DISEASE. 

The  symptoms  of  a  spinal  disease,  whether  or  not  that  disease  is 
amenable  to  surgical  treatment,  will  de]:)end  npon  the  nature  of  the 
disease  and  the  part  of  the  spinal  cord  and  nerve  roots  that  have  be- 
come affected.  Some  diseases  attack  particular  tracts  or  groups  of 
nerve  cells;  (sthers  are  destructive  in  nature — cells,  fibers,  or  entire 
rracls  being  destroyed;  in  still  others  the  functions  of  cell  groups 
and  conducting  fibers  are  inhibited  by  pressure,  and  in  the  early 
stages  little  or  no  actual  injury  occurs.  It  is  characteristic  of  all  of 
rliese  ^  arieties,  hoAvever,  that  sooner  or  later  secondary  destruction — 
ascending  or  descending  degeneration — ^occurs.  The  early  symptoms 
will  de])end  uuiinly  upon  the  parts  of  the  spinal  cord  first  affected. 
Thus,  diseases  which  cause  a  localized  increase  of  pressure  will  often 
give  early  iintei-ior  or  posterior  root  symptoms,  either  spasms  or 
weakness  or  paralysis  of  muscles  or  pain  or  other  sensory  disturb- 
ances. Associated  with  these  early  symptoms  there  is  usually  more, 
or  less  rigidity  of  the  spinal  column.  The  stiffness  of  the  back  is 
generally  a  defensiAe  phenomenon,  because  the  pain  is  generally 
made  worse  by  movements  of  Ihe  back  or  b}^  sudden  shocks  to  the 
spine  as  occur  in  sneezing  and  coughing.  The  scoliosis  which  is 
often  seen  in  spinal  compression  due  to  tumor  is  also  to  be  explained 
as  a  defensive  phenomenon. 

After  the  root  symptoms  have  existed  for  a  certain  time  (and  the 
period  may  extend  over  months  or  many  years),  symptoms  referable 
to  the  cord  appear.  These  are  either  weakness  or  paralysis  of  groups 
of  muscles  or  of  entire  extremities,  and  sensory  disturbances  due  to 
interruption  of  centripetal  fibers  in  the  white  columns  or  gray  matter 
of  the  cord.  The  progression  of  symptoms  is  sometimes  very  slow, 
extending  over  months  or  years,  with  frequent  remissions,  or  it  is 
more  rapid,  sensory  and  motor  loss  becoming  marked  and  extensive 
within  a  short  time.  These  are  soon  followed  by  disturbances  in  the 
functions  of  the  bladder  and  rectun),  and,  finally,  with  uiarked  tro- 
phic disturbances,  decubitus  and  edema  of  the  extremities. 

The  above  is  ihe  general  course  of  symptoms  when  the  s[)iual  cord 
is  subjected  to  a  grudually  increasing  pressure  from  without.  When, 
on  the  other  hand,  the  disease  originates  within  the  cord  substance 
itself,  the  progression  of  symptoms  is  usually  a  somewhat  different 
one.  While  pain  may  be  an  early  symptom,  it  is  generally  absent  in 
222 


SYMPTOMATOLOGY.  228 

(he  early  stages  oi  intrainednllary  disease.  The  first  syin[)toms  are 
generally  motor — Aveakness  and  atrophy  of  muscles  or  muscle  groups^, 
with  gradual  extension  until  more  or  less  of  <me  oi-  of  sevei'al  ex- 
tremities is  alfected.  With  these  early  motor  symptoms  there  are 
sensory  disturbauceh  of  the  dissociated  type,  or  sensation  renuiins 
uormal.  The  pati.MUs  ollen  comijlain  of  a  feeling  of  numhness  oi- 
cold  in  the  limbs. 

In  the  first  variety  of  disease,  i.  e..  in  which  pressure  ujion  the  cord 
I'rom  without  occurs,  the  sensory  and  motor  symptoms  soonei-  or 
later  have  a  distinct  level  character;  in  the  primary  intramedullary 
disease  there  may  be  tli^?  same  evidence  of  a  level  lesion.  In  many 
cases  of  intramedullary  disease,  however,  the  affection  spi'eads  up- 
ward (and  downward)  in  an  iiregulai-  way,  affecting  pAvis  of  the 
various  fiber  tracts  so  that  no  distinct  level  can  be  recognized.  If  a 
level  of  the  disease  is  observed,  it  may  be  shifted  upward  by  the  grad- 
ual advance  of  the  disease.  Similarly,  in  some  extramedullary  dis- 
v-ases  (leptomeningitis,  pachymeningitis)  the  level  of  the  disease  may 
be  slowly  shifted  upward  with  the  advance  of  the  inflammatory 
process. 

From  AA'hat  has  been  said,  it  is  clear  that  the  recognition  of  the 
.sequence  of  the  symptoms  is  very  important  for  the  diagnosis  and 
correct  valuation  of  the  syni proms  of  spinal  diseases. 

1.  The  sensory  disturbances  due  to  spinal  disease  affect  the  three  ele- 
mentary sensatiojis — touch.  p;'in.  and  temperature.  In  lesions  witliin 
Ihe  substance  of  the  spinal  coid.  pain  or  temperature  sense  (if  affected 
at  all)  is  diminished  or  lost,  but  it  is  the  entire  pain  or  the  entire 
temperature  sense.  In  root  lesions,  on  the  other  hand,  Ave  regularly 
observe  the  peripheral  type  of  sensory  disturbance  described  by 
Henry  Head.  When  a  posterior  root  lesion  is  suspected  we  must 
examine  separately  for  superficial  and  deep  pain  sense  disturbance, 
and  for  disturbances  in  the  protopathic  (above  45°  and  beloAv  20° 
C.)  and  the  epicritic  (between  25°  and  40°  C.)  temperature  sense. 
In  the  peripheral  nerves  there  is  a  close  connection  betAveen  the  sen- 
sation of  pressure,  of  painful  pressure,  and  the  power  of  recognition 
of  the  position  of  the  limbs,  or  of  passiA'^e  movements,  while  (accord- 
ing to  Head)  in  spinal  disease  the  poAver  of  recognizing  the  direc- 
tion and  nature  of  passive  movements  and  of  the  sense  of  pressure 
iriav  bv  distinct  from  deep  muscle  sense. 

The  sensory  symptoms  are  either  subjective  or  objective.  Under 
the  first  heading  are  included  pain  and  paresthesia;  under  the  sec- 
ond, a  gi-eat  variety  of  distur-bances  of  sensation  discovered  by  physi- 
cal examination. 

The  ])ain  of  sjjinal  disease  nuiy  vary  nnich  in  its  intensity.  Disease 
of  or  pressure  on  posterior  spinal  I'oots  Avill  cause  typical  root  pains 


224  WAR    SURGEEY    OF    THE    NERVOUS    SYSTEM. 

usually  referred  to  the  periphery — down  one  or  the  other  limb,  to 
part  of  the  chest  or  abdomen.  The  so-called  intercostal  neuralgia 
is  most  often  a  real  root  pain,  and  recent  investigations  have  demon- 
strated that  some,  at  least,  of  the  indefinite  abdominal  disturbances 
complained  of  by  patients  are  due  to  sensitive  cutaneous  areas  on 
the  abdominal  wall.  In  the  so-called  *'•  neuritis '"  of  one  of  the  ex- 
tremities, unless  its  cause  has  been  determined,  we  must  always  be 
on  the  lookout  for  a  possible  spinal  root  lesion.  Man}"  patients  with 
spinal  lesions,  especially  with  intradural  new  growths,  complain  of 
pain  in  the  back  which  is  different  from  root  pain  and  which  is,  I 
believe,  due  to  irritation  of  the  sensitive  inner  surface  of  the  dura 
mater. 

When  paresthesise  are  complained  of  there  is  usually  a  "  pin-and- 
needle  sensation.*'  a  feeling  of  numbness  or  coldness,  or  burning  sen- 
sations. These  paresthesia?  are  sometimes  referred  to  particular 
nerve  areas,  but  more  often  are  referred  to  the  peripheral  parts  of 
extremities.  In  the  former  case  their  localization  has  considerable 
diagnostic  value,  especially  when  an  objective  sensory  disturbance 
is  found  over  the  same  area. 

Objective  sensory  disturbances  mainly  consist  of  increase,  diminu- 
tion, or  disappearance  over  definite  areas  of  one  or  more  of  the  three 
main  forms  of  sensation — touch,  pain,  or  temperature.  In  complete 
destructions  of  the  cord  at  any  level,  there  is  a  total  loss  of  all  sensa- 
tion below  the  affected  level.  In  partial  lesions  of  the  cord  the 
sensory  disturbance  will  depend  upon  the  level  of  the  lesion  and  the 
tracts  affected. 

A  hj^persensitiveness  to  touch,  pain,  or  heat  and  cold  often  occurs 
at  the  level  of  a  spinal  lesion  and  is  probably  due  to  irritation  of 
posterior  spinal  nerve  roots  at  that  level.  If  the  function  of  a  pos- 
terior nerve  root  at  the  level  of  the  disease  is  totally  interfered  with, 
there  may  be  an  anesthesia  over  the  area  of  distribution  of  the  root, 
but  this  rarely  occurs  unless  three  roots  at  least  are  affected.  Hence 
we  may  find  at  or  above  the  general  level  of  the  sensory  disturbances 
a  hyperesthesia  or  an  anesthesia  which  is  radicular  in  character,  and 
when  this  occurs  on  one  side  of  the  body  only,  we  may  be  certain  that 
the  lesion — if  a  localized  one — is  on  that  side  of  the  spinal  cord. 

The  amount  of  disturbance  of  sensation  below  the  level  of  the  lesion 
will  depend  upon  the  degree  of  interference  with  fiber  tracts.  The 
amount  of  tactile  disturbance  is  not  apt  to  be  as  marked  as  that  of  the 
other  sensations  for  reasons  that  have  been  explained  elsewhere,  for 
tactile  sensation  is  lost  only  when  there  is  extensive  disease  of  the 
cord.  Loss  of  tactile  sense  does,  however,  occur  alone,  although  in 
most  cases  it  is  associated  with  changes  in  the  pain  and  temperature 
senses. 


SYMPTOMATOLOGY.  225 

Disturbances  in  tactile  and  deep  muscle  sensation  will  regularly 
follow  a  disease  of  both  posterior  white  columns  of  the  cord,  but 
numerous  cases  are  on  record  where  disease  of  one  posterior  column 
did  not  cause  any  tactile  disturbance.  This  can  only  be  understood 
on  the  basis  that  the  fibers  for  tactile  sensation  run  in  a  bilateral 
path  and  that  one  tract  can  take  up  the  functions  of  the  other,  if 
necessary.  Recently,  Head  and  Thompson  have  claimed  that  the 
power  of  discrimination  between  two  points  on  the  skin  is  diminished 
or  lost  in  posterior  column  disease,  and  that  if  only  one  posterior 
column  is  affected,  this  diminution  or  loss  will  be  found  only  on  the 
affected  limbs  of  that  side.  If  the  statements  of  Head  and  Thomp- 
son are  correct  (as  they  seem  to  be),  the  diminution  or  loss  of  the 
power  of  discrimination  is  a  valuable  diagnostic  symptom. 

Loss  of  the  sense  of  vibration  (pallanesthesia  of  Oppenheim)  may 
be  an  early  symptom  of  sensory  disturbance  in  tumors,  compression 
paraplegia,  multiple  sclerosis  and  sj^philis  of  the  spinal  cord. 

In  the  beginning  of  pressure  upon  fiber  tracts  of  the  cord  there 
may  be  very  slight  sensory  disturbance,  which  can  be  discovered  only 
by  the  most  careful  examination.  If  the  posterior  columns  are  most 
affected,  the  sensory  loss  will  involve  mainly  tactile  (hypesthesia  or 
anesthesia)  and  deep  muscle  sense.  If  the  lateral  columns  are  also 
affected,  pain  (hypalgesia  or  analgesia)  and  temperature  sensation 
are  also  involved. 

Usually  the  temperature  and  pain  senses  are  equally  affected ;  occa- 
sionally the  one  or  the  other  sensation  is  preserved.  Sometimes  the 
recognition  of  cold  is  preserved  while  that  of  warm  is  lost,  or  vice 
versa ;  at  other  times  there  is  a  perversion  of  sensation,  heat  being  felt 
as  cold  and  cold  as  heat.  Instead  of  pain,  there  may  be  a  burning  or 
itching  sensation.  This  dysesthesia  was  first  described  by  Charcot; 
it  has  often  been  observed  in  stab  wounds  of  the  cord. 

When  the  disturbances  of  the  pain  and  temperature  senses  are  due 
to  a  lesion  of  the  lateral  white  columns,  an  ataxia  of  the  affected 
limbs  is  often  observed  (spinocerebellar  tracts  in  lateral  columns). 

Marked  disturbance  of  the  pain  and  temperature  senses  with  little 
or  no  affection  of  the  iactile  sense  is  known  as  "  dissociation  of  sensa- 
tions," and  is  especially  frequent  in  disease  of  the  gray  matter  of 
the  cord  (syringomyelia,  hematomyelia,  central  tumors  of  the  cord). 
Until  recently  it  was  believed  that  this  dissociation  of  sensibility 
always  signified  central  disease  of  the  cord,  but  we  now  know  that  it 
may  occur  in  disease  of  a  lateral  column  and  is  not  so  very  rare  in 
extramedullary  tumors  of  the  cord  which  cause  the  Brown- Sequard 
symptom  complex.  When  these  dissociated  sensibility  disturbances 
are  associated  with  early  muscular  paralyses  and  early  wasting  of 
special  muscles  or  groups  of  muscles,  the  diagnosis  of  central  disease 
of  the  cord  is  more  probable, 
13764—17 15 


226  WAK   SURGEEY   OF    THE    NEEVOUS   SYSTEM. 

Finally,  the  physician  must  never  forget  that  severe  disease  of  the 
cord  may  exist  without  any  sensory  disturbance ;  that,  for  example,  a 
tumor  on  the  anterior  surface  of  the  spinal  cord  may  not  cause  any 
objective  sensory  disturbances  for  a  long  time. 

2.  Interference  with  the  pyramidal  tracts  in  any  part  of  their  spinal 
course  will  cause  motor  symptoms  whose  character  will  depend  upon 
the  amount  of  the  interference.  Thus  there  may  ensue  paresis  or 
paralysis  with  or  without  spacticity,  changes  in  the  cutaneous  muscle 
and  tendon  reflexes  or  disappearance  of  reflexes.  The  amount  of 
paralysis  will  depend  upon  the  degree  of  interference  with  the  con- 
ducting fibers  in  the  pyramidal  tracts.  Although  many  writers  have 
attempted  to  formulate  a  general  plan  of  arrangement  of  the  fibers  for 
the  different  parts  of  the  limbs  in  the  columns  of  the  cord,  there  is, 
as  yet,  little  unanimity  on  this  subject. 

Lesions  of  the  pyramidal  fibers  Avill  cause  an  increase  in  the  reflexes 
below  the  level  of  the  lesion  in  most  (but  not  all)  instances.  The  re- 
flexes are  either  cutaneous,  tendinous,  or  periosteal. 

In  the  upper  extremities  the  important  reflexes  which  become  ex- 
aggerated when  there  is  a  lesion  in  the  pyramidal  tracts  above  the 
level  of  the  reflex  centers  in  the  spinal  cord  (except  in  the  instances 
to  be  mentioned  later)  are  the  triceps,  biceps  and  radial  periosteal 
reflexes. 

The  most  important  abdominal  reflexes  are  the  upper  and  lower 
abdominal  and,  in  the  male,  the  cremasteric  reflexes.  These  may  be- 
come exaggerated  with  pyramidal  tract  disease,  or  may  be  diminished 
or  absent  under  conditions  Avhich  will  be  spoken  of  in  the  next 
chapter. 

In  the  lower  extremities  compression  or  a  lesion  of  the  pyramidal 
tracts  will  cause  an  exaggeration  of  the  patellar  or  quadriceps  tendon 
and  the  Achilles  tendon  reflexes.  As  explained  in  a  preceding  chap- 
ter the  p3^ramidal  fibers  have  a  kind  of  inhibitory  effect  on  muscle 
tone  and  hence  upon  tendon  reflexes,  and  fibers  from  the  posterior 
nerve  roots  and  also  fibers  in  the  cerebellospinal  tracts  exert  a  stimu- 
lating influence  upon  the  cells  in  the  anterior  horns  and  hence  upon 
muscle  tone. 

Therefore  the  patellar  reflexes  (and  in  a  similar  manner  other 
tendon  reflexes)  are  increased  by  irritative  conditions  of  the  posterior 
spinal  roots,  disease  in  the  pyramidal  tracts  by  diffuse  affections  of 
the  spinal  cord.  The  knee  jerks  are  diminished  or  disappear  in 
disease  of  the  anterior  spinal  roots,  in  complete  destruction  of  the 
posterior  roots  and  posterior  columns,  in  disease  of  the  gray  matter 
at  the  level  of  the  cells  which  form  part  of  the  reflex  arc,  in  com- 
plete destruction  of  the  cord  above  this  level  and  in  deep  coma  and 
deep  anesthesia. 


SYMPTOMATOLOGY.  227 

Marked  increase  of  any  one  of  these  may  result  in  clonic  contrac- 
tions. In  general  Achilles  tendon  or  ankle  clonus  is  most  frequent. 
Lesions  of  the  tracts  under  discussion  may  also  cause  the  appearance 
of  pathological  reflexes,  the  Babinski  phenomenon  (dorsal  flexion  of 
great  toe  when  sole  of  foot  is  stroked)  ;  "  Mendel-Bechterew  ''  (plan- 
tar flexion  of  second  to  fifth  toes,  frequently  with  separation  of  toes, 
when  the  region  of  the  fifth  metatarsal  bone  is  tapped)  ;  "  Chaddock  '' 
(dorsal  flexion  of  large  toe  upon  irritation  of  the  inner  or  outer  side 
of  foot  below  the  inner  or  outer  malleolus)  ;  "Oppenheim"  (dorsal 
flexion  of  the  large  toe  when  the  muscles  of  the  calf  of  the  leg  are 
grasped  with  the  hand  and  massaged  in  a  downward  direction)  ; 
"  Gordon  "  (when  the  muscles  of  the  calf  are  suddenly  squeezed  with 
the  fingers  of  one  hand),  etc. 

The  extensor  reflex  of  the  large  toe,  named  "  Babinski,"  after  its 
discoverer,  is  most  often  present  in  spinal  disease ;  the  "  Mendel- 
Bechterew  "  is  very  frequent,  especially  when  there  is  marked  spas- 
ticit3^ 

The  tibial  periosteal  reflex,  which  consists  of  a  contraction  of  the 
adductors  of  the  thigh  when  the  inner  surface  of  the  tibia  is  tapped 
with  a  percussion  hammer,  is  regularly  exaggerated  with  pyramidal 
tract  lesions.  Sometimes  the  adductors  of  the  opposite  (affected) 
limb  Avill  contract  when  the  patellar  tendon  of  the  normal  side  is 
tapped  (contralateral  adductor  reflex).  This  reflex  is  due  to  irri- 
tation of  the  uncrossed  pyramidal  fibers  and  is  very  often  to  be  ob- 
tained. The  Eeflex  de  defense,  to  which  Babinski  has  recently  again 
called  attention,  is  an  expression  of  the  automatism  of  the  spinal 
cord  when  freed  from  the  influence  of  higher  centers.  Defensive 
movements  due  to  automatic  spinal  activity  have  been  long  known 
to  physiologists.  It  remained  for  Babinski  to  demonstrate  their 
value  in  spinal  localization.  In  paraplegia  from  compression  of  the 
spinal  cord,  for  example,  when  a  systematic  examination  of  these  de- 
fensive reflexes  from  the  lower  extremities  upward  is  made,  part  of 
the  cord  beyond  which  no  reflexe  de  defense  occurs  corresponds  to 
the  lower  limit  of  the  compression.  These  reflexes  (e.  g.,  dorsal 
flexion  of  foot,  flexion  at  knee  and  at  hip  when  plantar  surface  of 
foot  of  paralyzed  lower  extremity  is  irritated,  flexion  at  wrist  and 
elbow  on  irritation  of  dorsum  or  plantar  surface  of  hand,  etc.)  are 
especially  present  in  level  lesions  such  as  transverse  myelitis  or  com- 
pression paraplegia,  due  to  fracture  of  the  spine,  extramedullary 
tumors,  etc.  The  contralateral  plantar  reflex  (slow  dorsal  flexion 
of  the  toe  of  the  paralyzed  leg  on  irritation  of  the  sole  of  the  healthy 
foot)  is  sometimes  observed,  when  all  other  signs  of  pyramidal 
tract  lesion  are  wanting.  I  have  twice  observed  this  crossed  toe  reflex 
among  the  early  signs  of  spinal  compression. 


228  WAR    SURGEEY    OF    THE    NERVOUS   SYSTEM. 

3.  Bladder  and  rectal  disturbances  are  very  frequent  in  diseases  of 
the  spinal  cord.  The  gray  matter  of  the  sacral  cord  and  conns 
terminalis  contains  centers  for  the  bladder,  rectum,  and  sexual  ap- 
paratus. The  control  of  the  bladder  is  due  to  the  tonic  contraction  of 
the  vesical  sphincter.  If  the  bladder  is  distended,  the  sensory  nerves 
are  irritated  and  stimuli  are  carried  to  the  spinal  centers  and 
through  the  third  and  fourth  anterior  sacral  roots  to  the  bladder 
muscle.  There  is  an  antagonism  between  the  sphincter  and  the  de- 
trusor of  the  bladder,  and  it  is  probable  that  stimulation  of  the 
sphincter  is  regularly  associated  with  an  inhibition  of  the  detrusor, 
although  both  are  controlled  by  centers  in  the  brain  and  by  volition. 

Disturbances  of  the  bladder  may  therefore  result  from  disease  of 
any  part  of  the  spinal  cord.  If  the  disease  is  located  above  the  spinal 
centers  for  the  bladder,  the  control  of  higher  centers  is  cut  off,  the 
patient  may  lose  volitional  control,  the  bladder  empties  itself  reflexly 
as  soon  as  it  is  distended,  or  it  becomes  overdistended  and  overflow 
occurs.  If  the  centers  in  the  cord  are  destroyed,  all  control  is  lost 
and  there  is  incontinence  of  urine.  The  rectum  is  controlled  by  a 
similar  nervous  mechanism.  The  earliest  bladder  and  rectal  symp- 
toms of  spinal  disease  are  generally  retention  or  difficulty  in  starting 
the  expulsion  of  the  urine,  and  constipation.  Complete  incontinence 
of  urine  may  occur  without  rectal  disturbance,  but  constipation  is 
more  frequent.  Finally,  incontinence  of  urine  and  of  feces  occurs 
as  a  regular  symptom  of  advanced  lesion  of  the  spinal  cord  at  any 
level.  Disturbances  of  the  sexual  organs  are  frequently  associated 
with  bladder  and  rectal  disturbances. 


Part  5. 

THE    SYMPTOMS   OF   SPINAL    DISEASE    AT    DIFFERENT 
LEVELS  AND  IN  DIFFERENT  REGIONS  OF  THE  CORD. 

Because  of  the  existence,  at  different  levels  of  the  spinal  cord,  of 
centers  for  particular  and  peculiar  functions — the  control  of  the 
dilator  of  the  pupil,  of  the  bladder,  the  rectum,  the  sexual  function, 
etc. — it  follows  that  disease  in  different  segments  of  the  cord  will  be 
characterized  not  only  by  motor  and  sensory  symptoms  from  inter- 
ference with  cells  in  the  gray  matter  and  with  ascending  and  descend- 
ing fiber  tracts,  but  also  by  disturbances  in  these  peculiar  functions. 

Thus  disease  in  the  cervical  region  Tvill  cause  pupillary  symptoms, 
and  hence  such  pupillary  disturbances  have  great  importance  for 
spinal  localization.  If  the  spinal  disease  exists  in  those  segments  o£ 
the  cord  in  which  lie  the  reflex  centers  for  the  cutaneous  abdominal 
reflexes,  these  will  be  lost,  and  this  loss  of  one  or  other  abdominal 
reflex  will  indicate  the  level  of  the  disease  to  Avhich  all  the  other 
symptoms  and  signs  have  to  be  correlated. 

Although  a  disease  in  any  part  of  the  cord  may  cause  vesical  and 
rectal  disturbances,  it  is  especially  in  conus  and  cauda  equina  dis- 
eases that  early  interference  with  the  emptying  of  the  bladder  and 
rectum  occurs,  and  hence  early  loss  of  one  or  both  of  these  functions 
has  diagnostic  significance. 

Similarly,  a  disease  at  the  level  of  the  reflex  centers  for  the  patellar 
or  the  ankle  jerks  may  cause  an  isolated  loss  of  the  one  or  the  other 
on  one  or  both  sides,  and  the  diagnostic  importance  of  such  a  loss 
must  not  remain  unrecognized. 

The  motor  and  sensory  sjanptoms  due  to  a  lesion  of  the  cord  vary 
within  wide  limits,  and  depend  upon  the  amount  of  Avhite  and  of 
gray  matter  affected.  In  the  cervical  and  lumbar  cord,  the  gray 
matter  occupies  a  considerable  part  of  the  cord,  hence  in  these  parts 
of  the  cord  early  muscle  atrophies  are  frequent. 

From  vrhat  has  been  stated  in  the  preceding  chapters,  it  should  be 
possible  for  the  physician  to  determine  the  location  of  a  spinal  dis- 
ease from  the  symptoms  and  signs  presented.  In  the  present  chapter 
certain  peculiarities  of  symptoms  at  different  levels  of  the  cord  will 
be  described. 

1.  Disease  in  the  upper  cervical  (from  the  first  to  the  fifth  cervical) 
segments  is  sometimes  rapidly  fatal,  but  life  may  be  sufficiently  pro- 
longed to  observe  oculopupillary,  respiratory,  and  cardiac  symptoms. 

229     . 


230  WAR    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 

The  ciliospinal  center  lies  in  the  gray  matter  of  the  eighth  cervical 
and  first  dorsal  segment;  it  exercises  a  control  over  the  cervical 
sympathetic  ganglia  and  is  itself  controlled  by  higher  centers.  When 
any  part  of  the  sympathetic  oculopupillary  innervation  is  inter- 
fered with,  a  paralytic  miosis  (in  which  the  pupil  will  no  longer 
dilate  in  the  dark  and  a  difference  between  the  two  pupils  (ani- 
sokoria)  occurs),  a  narrowing  of  the  palpebral  fissure,  and  a  moderate 
degree  of  enophthalmus  (sinking  back  of  the  eyeball),  results. 
I^espiratory  disturbances  due  to  interference  with  the  centers  for  the 
phrenic  nerve  and  diophragm  (Cg-Cg)  has  been  frequently  observed. 
These  respiratory  disturbances  are  frequently  caused  by  a  combi- 
nation of  phrenic  nerve  and  medullary  lesions.  In  several  instances, 
however,  I  have  noted  that  the  diaphragm  was  not  paralyzed  in  spite 
of  extensive  disease  in  the  third  to  fifth  cervical  segments.  It  seems 
to  me  probable  that  the  diaphragm  receives  some  innervation  from 
still  higher  centers. 

Slowing  and  irregularity  of  the  pulse  is  characteristic  of  high 
cervical  lesions,  and  is  probably  due  to  disturbances  in  the  medulla 
oblongata,  as  are  also  the  very  high  temperatures  (103°  to  106°  F.) 
that  are  often  observed. 

In  these  high  cervical  lesions  vasomotor  symptoms  with  disturb- 
ances of  sweating  of  the  face  (Horner's  symptom  complex)  fre- 
quently occur.  There  may  be  early  spastic  hemiplegia  of  an  upper 
and  lower  extremity  with  partial  loss  of  sensation  on  the  other  side. 
There  may  be  neuralgic  symptoms  referable  to  the  occipital  minor 
and  major,  supraclavicular  and  auricularis  magnus  nerves,  and 
atrophy  of  the  sternomastoids,  trapezii,  and  other  superficial  and 
deep  muscles  of  the  neck. 

2.  Lesions  between  the  sixth  cervical  and  first  dorsal  segments. — In 
these  there  is  frequently,  but  not  always,  a"  difference  between  the  size 
of  the  two  pupils  (anisokoria)  due  to  a  miosis  on  the  side  of  the 
lesion,  with  a  diminution  or  loss  of  the  triceps  reflex  on  one  or  both 
sides,  marked  weakness  of  the  triceps  muscle  and  sensory  disturb- 
ances, especially  on  the  radial  side  of  one  or  both  upper  extremities. 
The  presence  of  the  radius  reflex  (blow  on  the  styloid  process  of 
the  radius  causing  supination  of  forearm)  with  absence  of  triceps 
reflex  is  especially  characteristic  of  a  lesion  at  the  sixth  cervical 
segment,  and  I  have  frequently  seen  this  combination  in  extramedul- 
lary  tumors  at  this  level.  The  sensory  and  motor  symptoms  may 
affect  one  or  both  upper  extremities,  or  in  addition  one  or  both  lower 
extremities.  In  the  so-called  Dejerine-Klumpke  paralysis  the  lesion 
is  at,  the  level  of  the  eighth  cervical  and  first  dorsal  roots,  and  the 
small  muscles  of  the  hands  and  the  flexors  of  the  forearm  are 
especially  affected.     Oculopupillary  symptoms  are  frequent. 


SYMPTOMS   AT   DIFFERENT   LEVELS.  231 

3.  Lesions  between  the  eighth  and  twelfth  dorsal  segments  are  char- 
acterized by  absence  of  the  abdominal  reflexes  and  by  root  anes- 
thesias over  the  abdomen.  Sometimes  the  upper  abdominal  reflex 
on  one  ov  both  sides  is  absent  while  the  lower  is  preserved,  and  vice 
versa,  and  by  this  means  it  has  often  been  possible  for  us  to  moria 
exactly  localize  the  lesion  of  the  cord  at  the  level  of  the  centers  for 
the  upper  (D8  to  D9)  or  the  lower  (DlO  to  D12)  abdominal  reflexes. 
The  abdominal  muscles  may  not  be  paralyzed,  even  though  a  com- 
plete transverse  lesion  above  the  eighth  dorsal  segment  exists.  I  have 
under  my  care,  at  the  present  time,  a  patient  with  a  complete  crush 
of  the  cord  at  the  level  of  the  second  dorsal  segment,  in  whom  the 
abdominal  muscles  are  not  paralyzed.  Hyptonia  or  paralysis  of  the 
abdominal  muscles  is  sometimes  a  valuable  level  sign  of  spinal  disease. 
When  the  patient  coughs,  the  bulging  of  the  abdominal  muscles  on 
either  side  is  very  evident.  Sometimes,  even  if  there  is  no  paralysis 
of  the  abdominal  muscles,  the  difference  between  the  reaction  of  the 
muscles  to  the  faradic  current  on  the  one  or  the  other  side  will  be 
very  distinct.  Girdle  pains  are  most  frequent  in  the  middorsal 
region. 

4.  Lesions  in  the  lumbar  cord  are  characterized  by  diminution  or  loss 
of  the  patellar  tendon  reflex  on  one  or  both  sides  if  the  disease  be  at 
the  level  of  or  below  the  second  lumbar  segment  and  is  frequently 
associated  with  early  disturbances  in  the  functions  of  the  bladder  and 
rectum.  On  account  of  the  small  size  of  the  lumbar  and  sacral  seg- 
ments of  the  cord,  disease  most  often  affects  a  large  part  of  the 
lumbosacral  cord,  and  it  is  often  difficult  to  differentiate  between  the 
sjanptoms  of  this  part  of  the  spinal  cord  and  those  of  the  cauda 
equina.  The  paralysis  is  usually  of  the  flaccid  type  with  marked 
atrophy  of  muscles.  The  knee  jerks  and  the  cremasteric  reflexes 
are  usually  lost,  while  the  ankle  jerks  remain  active  or  are  exagger- 
ated, perhaps  with  ankle  clonus. 

6.  Lesions  of  the  epiconus. — Minor  has  attempted  to  distinguish  the 
epiconus,  in  which  he  includes  the  fourth  and  fifth  lumbar  and  the 
first  and  second  sacral  segments.  The  prominent  symptoms  of  an 
epiconus  lesion  are,  according  to  Minor,  a  degenerative  paralysis 
of  the  glutei*  muscles,  with  especially  early  loss  of  powder  in  the 
peronei  muscles.  The  tibialis  anticus  is  usually  not  affected;  the 
ankle  perks  and  plantar  reflexes  disappear  early,  while  the  knee 
jerks  persist.  It  is  very  rare,  however,  that  a  pure  epiconus  lesion 
can  be  diagnosticated  from  the  signs  and  symptoms. 

6.  Lesions  of  the  conus  and  cauda  equina. — Clinically  we  are  accus- 
tomed to  include  in  the  conus  the  three  lower  sacral  and  the  coccygeal 
segments — that  part  of  the  cord  which  lies  behind  the  twelfth  ctorsai 
and  the  first  lumbar  vertebrae.  Disease  of  this  portion  of  the  cord 
can  frequently  not  be  distinguished  from  an  affection  of  the  cauda 


232  WAR   SURGEEY   OF    THE    NERVOUS   SYSTEM. 

equina.  Disease  of  the  conns  is  characterized  by  retention  or  incon- 
tinence of  urine,  constipation  or  incontinence  of  feces,  impotence, 
anesthesia  over  the  scarum  and  around  the  anus  and  genitals,  without 
any  motor  or  reflex  disturbances  in  the  lower  extremities. 

In  disease  of  the  cauda  equina,  on  the  other  hand,  pain  in  the" 
small  of  the  back,  extending  into  the  perineum,  the  genitals,  and 
often  down  the  posterior  surfaces  of  the  thiglis  into  the  areas  of  dis- 
tribution of  the  peroneal  nerves,  is  far  more  frequent.  The  sensory 
loss  is  often  asymmetrical,  extending  down  the  posterior  surfaces  of 
the  thighs  and  outer  aspects  of  the  legs. 

The  lower  the  disease  of  the  nerves  of  the  cauda  equina  the 
smaller  the  number  of  roots  that  are  affected  and  the  smaller  is  the 
area  of  sensory  disturbance,  but  there  are  diseases  which  affect  both 
conus  and  nerves  of  the  cauda  equina  (soft  nev\'growths)  in  which 
there  is  very  little  sensory  loss.  The  characteristic  sensory  loss  in 
conus  and  cauda  affections  varies  within  wide  limits;  sometimes 
characteristic  segment  loss  occurs,  at  other  times  the  sensory  dis- 
turbances are  very  irregular.  In  both  conus  and  cauda  equina  lesions 
weakness  of  dorsal  flexion  of  one  or  both  feet  with  more  or  less  com- 
plete dropped  foot  occurs.  This  drop  foot  may  be  the  only  evidence 
of  a  motor  disturbance  in  the  lower  limbs. 

The  characteristic  symptoms  of  conus  and  cauda  lesions  are  pain 
in  the  back,  rectal  and  vesical  disturbances,  diminution  or  loss  of 
sensation  over  the  areas  of  distribution  of  the  sacral  nerves,  loss  of 
ankle  jerks  and  dropped  foot  on  one  or  both  sides  with  sensory  dis- 
turbances in  the  lower  lumbar  and  sacral  root  areas,  flaccid  paralyses 
and  atrophy  of  the  muscles  of  the  posterior  surface  of  the  thigh, 
of  the  leg,  and  the  foot. 

The  anesthesia  extends  over  the  mucous  membrane  of  the  rectum, 
bladder,  scrotum,  and  penis  (vulva  in  women),  around  the  anus, 
over  root  areas  clown  the  back  of  the  thigh,  etc. 

THE  BROWN-SEGTJARD  SYNDEOME. 

The  most  frequent  combination  of  sjmiptoms  in  spinal-cord  dis- 
ease is  the  Brown-Sequarcl  syndrome,  in  which  motor  symptoms 
occur  on  the  same  side  of  the  body  below  the  level  of  the  lesion,  and 
sensory  disturbances  on  the  other  side.  The  Brown- Sequard  symp- 
tom complex  occurs  where  one-half  of  the  diameter  of  the  cord  is 
affected,  and  in  its  typical  form  presents  the  following : 

I.  On  the  same  side  as  the  lesion: 

(a)  Motor  joaralysis  or  paresis,  due  to  the  interference  with  the 
pyramidal  tracts. 

(h)  Vasomotor  disturbances  due  to  interference  with  the  homo- 
lateral vasoconstrictor  fibers  in  the  lateral  columns. 


SYMPTOMS   AT    DIFFEKENT    LEVELS.  233 

(c)  Disturbances  in  deep  muscle  sense  (batliy anesthesia  of  Oppen- 
heira),  with  ataxia  due  to  interference  with  the  posterior  cohimns 
and  spinocerebellar  tracts. 

(d)  Superficial  cutaneous  hyperesthesia. 
II.  On  the  opposite  side: 

Disturbances  of  sensibility,  especially  those  for  pain  and  temper- 
ature (often  also  tactile). 

In  addition,  on  the  side  of  the  lesion  there  are  girdle  pains  and 
hyper-  or  anesthesia  due  to  the  nerve  roots  that  are  involved,  so  that 
(on  the  side  of  the  lesion)  the  sensory  disturbance  is  on  a  somewhat 
higher  level  than  on  the  opposite  side. 

If  the  lesion  involves  one-half  of  the  cord  in  the  lumbosacral 
regions,  the  motor  and  the  sensory  loss  are  usuall}^  on  the  same  side, 
because  at  this  low  level  few  sensory  fibers  have  already  crossed  to 
the  other  side. 

The  Brown-Sequard  syndrome  is  most  frequently  observed  after 
injur}^  of  the  cord  due  to  fractures  of  the  vertebrae  or  to  bullet  and 
stab  wounds.  It  also  occurs  in  spinal  tumors  and  spinal  syphilis, 
and  (rarely)  in  myelitis  and  in  multiple  sclerosis.  The  typical 
Brown-Sequard  symptoms  are,  however,  rarely  observed;  there  is 
usually  a  preponderance  of  motor  symptoms  on  one  and  sensory 
symptoms  on  the  other  side  as  an  indication  of  the  Brown-Sequard 
symptom  complex. 

In  some  cases  of  spinal  tumor  I  have  observed  a  reverse  condition, 
motor  symptoms  on  the  contralateral  and  sensory  symptoms  on  the 
homolateral  side.  The  explanation  for  this  will  be  given  in  the 
chapter  on  spinal  tumors. 

Dissociation  of  the  syringomyelitic  character  is  often  observed 
with  spinal  symptoms  of  the  Brown-Sequard  type;  on  the  side  of 
the  sensory  symptoms  tactile  sensation  is  normal  or  only  slightly 
disturbed,  while  the  pain  and  temperature  sense  is  markedly  affected 
or  completely  lost. 


Part  6. 
THE  OPERATION  OF  LAMINECTOMY. 

(Reprinted,  by  permission,  from  Dr.  Charles  Frazier's  Surgery  of  the  Spine. 
Copyriglit,  1916,  by  D.  Appleton  &  Co.) 

Anesthesia. — In  most  instances  the  operation  is  carried  out  under 
general  anestliesia,  although  occasions  have  arisen  when  I  have 
thought  a  general  anesthetic  might  be  undesirable,  and  under  such 
circumstances,  referred  to  below,  I  have  been  able  to  complete  the 
operation  under  local  anesthesia.  With  these  exceptions  ether  is  used 
in  my  clinic  and  administered  by  the  endotracheal  insufflation  method 
of  Meltzer.  The  apparatus  designed  by  my  associate.  Dr.  George  P. 
Miiller,  has  proven  in  every  respect  satisfactory;  it  is  less  compli- 
cated and  less  expensive  than  many  others  on  the  market.  The  tube 
is  introduced  with  the  Jackson  laryngoscope,  and  after  the  patient 
has  been  placed  on  the  operating  table  no  concern  need  be  given 
to  the  patient's  position,  except  as  above  noted,  other  than  to  avoid 
pressure  of  the  neck  upon  the  upper  edge  of  the  table.  Endotracheal 
insufflation  anesthesia  has  very  peculiar  advantages  in  spinal  opera- 
tions. As  the  term  implies,  anesthesia  is  maintained  by  ventilation 
of  the  lungs  with  ether  vapor  under  a  regulated  pressure.  The  venti- 
lation of  the  lungs  may  be  effectively  accomplished  entirely  with- 
out the  assistance  of  the  act  of  respiration,  and  indeed  oxygenation 
of  the  blood  is  adequately  maintained.  Whether  respiration  be  em- 
barrassed by  paralysis  of  the  intercostal  or  abdominal  muscles,  as 
it  sometimes  is  in  spinal  lesions,  or  by  the  prone  position  of  the  pa- 
tient on  the  table,  the  insufflation  of  the  lungs  with  air,  charged 
with  ether,  by  the  endotracheal  apparatus  is  quite  competent  not 
only  to  maintain  an  even  anesthesia,  but  to  oxygenate  the  blood  ade- 
quately throughout  the  operation.  For  these  reasons  the  use  of  the 
apparatus  is  strongly  to  be  recommended  not  only  as  a  matter  of 
convenience  but  as  a  means  of  increasing  the  margin  of  safety. 

Local  anesthesia. — -Under  certain  conditions,  notably  when  the  pa- 
tient's vitality  is  greatly  depreciated  by  the  disease  and  when,  as 
in  trauma  of  the  lower  cervical  cord  with  paralysis  of  the  inter- 
costal and  abdominal  muscles,  there  is  the  greater  risk  of  pneu- 
monia, I  have  resorted  to  local  anesthesia.  The  skin  and  musculo- 
aponeurotic  layers  are  readily  rendered  anesthetic  by  the  infiltra- 
tion of  0.5  per  cent  novocain,  and  while  it  might  be  possible  to 
234 


LAMINECTOMY.  235 

anesthetize  the  periosteum  of  spines  and  laminae,  though  not  so 
effectively,  when  the  time  comes  to  remove  these,  I  resort  to  nitrous 
oxid-oxygen  anesthesia.  Novocain  infiltration  of  the  cutaneous  and 
muscular  layers  with  nitrous  oxid-oxygen  anesthesia  for  the  skeletal 
work  has  proven  a  very  happy  combination  and  may  be  considered 
an  important  factor  in  minimizing  risks  in  desperate  cases.  The  pa- 
tient is  given  hypoclermatically  morphine  sulphate  0.01  and  atropine 
sulphate  0.0016  one-half  hour  before  the  operation;  the  skin  along 
the  projected  incision  is  infiltrated  with  0.5  per  cent  novocain  solu- 
tion, and  after  the  skin  flaps  are  reflected  on  either  side,  the  aponeu- 
rosis and  the  muscles  down  to  the  spines  and  laminae  are  infiltrated 
with  massive  doses  of  the  same  solution.  For  one  operation  250  c.  c. 
may  be  required.  When  the  spines  and  lamina?  are  exposed,  nitrous 
oxid-oxygen  is  given  and  continued  until  the  bone  work  is  com- 
pleted. The  spinal  dura  is  more  sensitive  than  the  cranial  dura 
and  before  it  be  incised,  either  it  must  be  injected  with  novocain 
or  the  nitrous  oxid-oxygen  continued. 

While  this  method  has  proven  satisfactory  in  a  number  of  cases,  I 
have  been  impressed  with  the  greater  effectiveness  of  regional  anes- 
thesia, especially  in  operations  upon  the  thoracic  region.  The  sen- 
sory supply  of  the  structures  in  the  field  of  operation  is  derived 
from  the  cutaneous  rami  of  the  posterior  primary  divisions  of  the 
spinal  nerves.  FolloAving  the  technic  for  alcoholic  injection  of  the 
intercostal  nerves,  as  many  nerves  on  either  side  as  may  be  neces- 
sary, according  to  the  number  of  laminae  to  be  removed,  are  in- 
jected with  0.5  per  cent  novocain  solution.  It  may  be  necessary  to 
supplement  these  primary  injections  with  injections  directly  in  the 
line  of  incision  and  subperiosteally  on  either  side  of  the  laminae. 
By  a  combination  of  these  injections,  I  have  been  able  to  open  the 
spinal  canal  for  various  lesions  without  the  aid  of  a  general  anes- 
thetic. 

One  or  two  stage  operation. — The  question  of  a  one  or  two  stage  op- 
eration is  often  the  subject  of  discussion,  but  I  do  not  believe  in  an 
attempt  to  settle  it,  either  pro  or  con,  in  an  arbitrary  manner.  Each 
case  is  a  law  unto  itself,  but  the  decision  rests  wtih  the  judgment  of 
the  operator.  I  depend  almost  altogether  upon  the  blood  pressure  as 
the  most  valuable  index  to  the  patient's  condition.  If  the  blood  pres- 
sure be  maintained  at  an  approximately  normal  line  in  the  prelimi- 
nary stage  of  exposure,  there  is  no  reason  whatsoever  for  discontinu- 
ing the  operation  until  a  second  sitting.  And  the  more  attention  one 
pays  to  the  control  of  hemorrhage  and  the  avoidance  of  unnecessary 
trauma,  the  less  frequently  will  the  operator  be  forced,  as  a  measure 
of  safety,  to  postpone  the  completion  of  the  operation  until  a  second 
sitting.  As  a  matter  of  fact,  I  have  had  to  resort  to  the  two-stage 
operation  but  twice.    The  pulse  rate  and  blood  pressure  are  recorded 


236  WAR   SUEGEEY    OF    THE    NEEVOUS   SYSTEM. 

on  a  special  chart  at  five-minute  intervals  by  an  assistant,  and  a 
glance  at  the  chart,  constantly  within  view  of  the  operator,  serves  to 
keep  him  accurately  and  continuously  informed  as  to  his  patient's 
condition. 

Instruments. — The  mechanics  of  removing  the  spines  and  laminae 
are  comparatively  simple,  and  few  instruments  are  required.  Each 
operator  may  determine  for  himself  the  instruments  with  which  he 
can  remove  the  spines  and  laminae  with  greatest  facility  and  with 
the  least  expenditure  of  time  or  infliction  of  damage.  While  a  great 
variety  of  instruments  has  been  suggested  and  recommended,  I  have 
found  a  modification  of  the  Liston  forceps  for  the  removal  of  the 
spinous  processes  and  rongeur  forceps  of  various  sizes  and  angles  for 
the  removal  of  the  laminae  meet  every  requirement.  As  with  all 
operations  upon  the  skeleton,  the  bone-cutting  instruments  should  be 
sharpened  before  every  operation.  Some  surgeons  employ  saws  for 
the  laminae,  such  as  the  Gigli  saw,  Horsley's  saw,  or  Doyen's  circular 
saw,  others  again  the  conical  trephine,  and  while  these  may  prove 
satisfactory  in  the  hands  of  those  who  use  them,  the  selection  of  one 
instrument  or  another  must  be  considered  as  matters  of  personal 
preference. 

In  addition  to  the  bone-cutting  instruments,  but  few  instruments 
appropriate  especially  for  spinal  operations  are  required  in  the  arma- 
mentarium. Among  these  may  be  mentioned  two  pairs  of  self-retain- 
ing retractors  with  curved  teeth  which  are  particularly  helpful  in 
that  they  maintain  an  even  and  constant  retraction  of  the  muscles 
throughout  the  operation  and,  at  the  same  time,  release  an  assistant's 
hands  for  other  duties.  Horsley's  wax  is  required  to  control  bleeding 
from  the  cut  sections  of  laminae.  Mosquito  forceps  may  be  required 
after  the  dura  is  opened,  and  for  cutting  the  theca  or  roots  a  pair  of 
iris  scissors.  For  the  separation  or  isolation  of  roots  and  sometimes 
for  retraction  of  the  cord  I  have  used  hooks  of  glass  instead  of  metal ; 
these  serve  a  twofold  purpose.  Being  fragile,  they  serve  as  a  con- 
stant reminder  to  operator  or  assistant  of  the  obligation  to  employ 
the  minimum  amount  of  traction  force,  and  as  they  are  nonconduc- 
tors, they  do  not  transmit  to  an  adjacent  root  or  to  the  cord  the  elec- 
tric current  that  we  may  be  using  for  identification  of  individual 
roots.  In  the  closure  of  the  wound  several  kinds  of  needles  should 
be  available :  For  the  dura,  a  small  cutting  edge,  curved  iris  needle ; 
for  the  splint  sutures,  a  full  curved  Hagedorn  needle ;  for  the  muscles 
or  fascia,  an  Emmet  needle;  and  for  the  skin  a  straight  Hagedorn 
needle.  The  suture  material  includes  arterial  silk,  iodin  catgut,  and 
silkworm  gut. 

Localization. — In  preparation  for  all  intraspinal  operations,  exclud- 
ing those  for  trauma,  but  more  particularly  for  resection  of  the  roots, 
some  means  should  be  adopted  for  accurate  localization  of  at  least 


LAMIISrECTOMY.  237 

one  spinous  process.  This  is  best  accomplished  by  selecting  for 
identification  the  spinous  process  about  the  middle  of  the  contem- 
plated laminectomy.  Using  the  seventh  cervical  or  vertebra  promi- 
nens  as  a  starting  point  in  the  cervicothoracic  region,  or  the  last 
thoracic  in  the  thoracicolumbar  region,  the  successive  spines  are 
counted  until  the  desired  one  is  reached  and  marked  Avith  an  aniline 
pencil.  A  strip  of  metal  is  fastened  to  the  skin  at  this  level  and  a 
rontgenogram  made.  The  latter  will  determine  whether  the  first 
calculation  be  correct. 

The  operation. — With  this  preliminary  operation,  with  the  patient's 
position  properly  adjusted,  skin  disinfected,  and  the  field  of  opera- 
tion surrounded  with  sterile  sheets,  the  operation  begins.  The  in- 
cision is  semilunar  in  shape,  so  that,  upon  reflection  of  the  flap,  ade- 
quate exposure  is  afforded  of  the  structures  beneath.  The  incision 
proportionate  to  the  ])redetermined  number  of  laminii?  to  be  removed 
should  be  long  enough  to  include  at  least  one  spinous  process  above 
and  below  the  contemplated  opening,  since  it  so  often  happens  that 
one  additional  lamina  above  or  below  may  have  to  be  removed.  This 
initial  incision  extends  to  the  level  of  the  intervertebral  fascia.  The 
margins  of  the  flap,  including  the  skin  and  subcutaneous  tissue,  are 
then  covered  with  cloths  as  a  means  of  protecting  the  deeper  struc- 
tures from  skin  contamination. 

The  incision  in  the  intervertebral  fascia  begins  in  the  median  line 
at  the  tip  of  the  spine  above  the  first  spine  to  be  removed,  and,  follow- 
ing closely  the  lateral  aspects  of  the  spines,  first  on  one  then  on  the 
other  side,  terminates  in  the  median  line  just  below  the  last  spine  to 
be  included  in  the  laminectomy.  The  incision  in  the  intervertebral 
fascia  is  made  with  a  heaVy  knife,  and  should  penetrate  the  muscular 
sheath.  The  separation  of  the  muscular  layer  from  either  side  of 
the  spines  and  from  the  laminse  may  be  done  rapidly  with  a  broad 
chisel.  The  preservation  of  the  periosteal  layer,  partially  at  least, 
makes  possible  more  or  less  bone  regeneration,  so  that  the  defect  con- 
sequent upon  the  removal  of  the  spines  may  be  in  part  repaired.  As 
a  matter  of  fact,  complete  bony  arches,  replacing,  the  original  laminae, 
have  been  found  at  secondary  laminectomies. 

At  this  stage  of  the  operation  there  will  be  more  or  less  bleeding; 
more  if  the  chisel  penetrates  the  muscles,  less  if  it  hug  closely  to  the 
spines,  but  hemorrhage  is  readily  controlled  b}^  tamponing  the  wound 
at  once  v^-ith.  compresses  wrung  out  in  hot  normal  salt  solution.  Upon 
separation  of  the  muscle  layer  on  one  side  the  wound  is  tamponed 
before  proceeding  with  the  other  side,  or  even  before  the  muscles 
have  been  separated  from  the  lamina^  below.  Thus,  hj  working  first 
on  one  side  then  on  the  other,  complete  separation  of  the  muscles 
from  spines  and  laminae  is  effected  with  a  minimum  amount  of  bleed- 
inirc,  and  by  the  time  this  has  been  accomplished  and  the  tampons 


238  WAE    SURGERY   OF    THE    NERVOUS  SYSTEM. 

removed,  hemorrhage  is  well  under  control.  It  may  be  necessary  to 
ligate  several  bleeding,  points  in  the  belly  of  the  muscle  or  in  the 
sheaths  and  aponeurosis,  at  which  level  the  largest  blood  vessels  will 
be  found.  Intramuscular  injections  of  adrenalin  solution,  as  recom- 
mended by  some,  are  unnecessary. 

The  self-retaining  retractors  are  now  introduced,  one  or  two  pairs, 
according  to  the  length  of  the  wound,  and  beneath  them,  covering 
the  exposed  muscle  surface,  are  spread  gauze  pads.  The  blades  of 
the  retractors  are  separated  sufficiently  to  bring  into  view  the  articu- 
lar processes  on  either  side.  Having  divided  with  a  heavy  bladed 
knife  the  ligamenta  interspinalis  above  and  below,  the  several  spinous 
processes  are  removed  one  by  one  with  bone-cutting  pliers  and  the 
corresponding,  laminae  with  rongeur  forceps.  In  removal  of  the 
laminae  an  opening  is  made  with  a  small  pair  of  forceps,  or,  as  in  the 
lumbar  region,  with  a  drill,  and  as  soon  as  the  space  is  large  enough 
the  heavy  forceps  are  substituted,  and  the  several  arches  to  either 
side  as  far  as  the  articular  processes,  if  necessary  for  proper  expo- 
sure, are  hastily  removed  piecemeal.  While  the  cord  is  protected 
throughout  the  spinal  canal  by  the  epidural  fat  and  in  the  lumbar 
region  by  the  ligamenta  subflava,  care  must  be  taken  to  avoid  in- 
juring the  cord  in  the  removal  of  the  laminse.  This  is  especially  true 
in  cases  of  marked  kyphosis,  where  the  dura  is  in  closer  contact  with 
the  arches,  and  in  fracture-dislocations,  where  the  cord  may  be  com- 
pressed by  the  displaced  vertebrae. 

Once  the  laminectomy  is  completed  and  before  the  dura  is  opened, 
the  operator  surveys  the  field  in  search  of  bleeding  points.  Hem- 
orrhage from  every  source  should  be  under  control  before  entering 
the  dural  sac,  and  to  this  end  the  operator  will  avail  himself  of  one 
means  or  another,  according  to  the  source  of  bleeding.  If  from  the 
bone,  sterile  wax  is  the  most  effective,  and  if  from  other  structures, 
heat  in  the  form  of  tampons  wrung  out  in  hot  saline  solution,  tam- 
jions  of  cotton  or  small  pieces  of  muscle  tissue  will  usually  meet 
every  contingency. 

The  subsequent  steps  of  the  operation  will  depend  upon  whether 
the  lesion  be  extradural  or  intradural.  Before  opening  the  dura  at 
least  a  careful  inspection  should  be  made  for  extradural  processes, 
possibly  a  tumor,  a  deformity  following  fracture,  tuberculous  foci 
or  what  not,  and  finding  the  lesion  extradural,  further  exposure  is 
obviated.  It  would  be  especially  undesirable  to  invade  the  subarach- 
noid space  and  expose  the  spinal  membranes  or  cord  to  infection, 
should  the  process  prove  to  be  tuberculous.  A  fusiform  swelling  of 
the  dural  sac,  if  present,  suggests  an  intradural  lesion  and  gives  a 
clew  as  to  its  location. 

Before  the  dura  is  exposed  to  view  the  thin  layer  of  fat,  together 
with  the  plexus  of  veins,  must  be  displaced  to  either  side.    A  careful 


LAMINECTOMY.  239 

inspection  of  the  dura  at  this  stage  may  bring  to  light  the  nature  of 
the  lesion.  Under  normal  circumstances  the  dura  is  of  a  bluish- 
white  color  and  of  about  the  thickness  of  the  dural  covering  of  the 
brain.  Discoloration  of  the  dura  with  or  without  the  presence  of 
granulation  tissue  bespeaks  an  inflammatory  process.  The  absence 
of  pulsation  is,  of  course,  most  suggestive  of  a  tumor,  although  both 
the  arrest  of  pulsation  and  the  oval  swelling  may  be  caused  by  a 
circumscribed  pachymeningitis.  To  open  the  dura  introduce  two 
silk  traction  sutures,  one  on  either  side,  mounted  on  small  curved 
needles,  which  enter  but  do  not  penetrate.  Slight  traction  upon 
these  sutures  frees  the  dura,  and  between  these  a  minute  incision  is 
made  with  a  small  scalpel  down  to  but  not  including  the  arachnoid. 
The  latter  lies  in  such  close  apposition  to  the  dura  that  in  some  cases 
even  with  care  the  scalpel  will  puncture  it  and  the  cerebrospinal  fluid 
gush  forth.  But  if  not  perforated,  the  arachnoid  will  balloon 
through  the  dural  incision  under  the  pressure  of  the  pent-up  fluid. 
The  dural  incision  is  lengthened  by  cutting  over  a  director  first  in  one 
direction,  then  in  another.  Before  incising  the  arachnoid,  four  ad- 
ditional traction  sutures  are  introduced  through  the  margin  of  the 
dura — two  above  and  two  below  those  already  in  place.  The  three 
pairs  of  traction  sutures  are  grasped  separately  with  mosquito  for- 
ceps, which  by  their  weight  alone  will  retract  the  dural  flaps  suffi- 
ciently to  afford  ample  inspection  of  the  subarachnoid  space.  But 
before  retracting  the  flaps  a  roll  of  cotton  a  centimeter  in  diameter 
and  the  length  of  the  dural  incision  is  laid  in  the  bed  of  the  wound 
to  the  outer  side  of  each  dural  flap.  These  cotton  rolls  will  absorb 
the  blood  that  may  gravitate  to  the  bottom  of  the  wound  during  the 
operation  and  prevent  its  entering  the  subarachnoid  space.  If  at  any 
time  they  become  saturated  fresh  ones  should  be  substituted.  While 
perfect  hemostasis  is  unquestionably  a  desideratum^  in  the  strictest 
interpretation  this  is  not  feasible,  and  yet  it  is  entirely  possible  to 
])revent  leakage  into  the  subarachnoid  space.  For  this  reason  the 
cotton  roll  plays  a  very  important  role. 

The  operator  pauses  now  to  inspect  the  field,  and  with  the  arach- 
noid still  intact,  his  observations  may  give  a  clew  to  the  seat  and 
character  of  the  lesion.  Under  normal  circumstances  the  cerebro- 
spinal fluid  pulsates  synchronously  with  the  pulse  and  with  respira- 
tion. In  many  instances  the  respiratory  movements  may  be  seen 
Avhen  the  pulsations  are  not  visible.  This  natural  phenomenon  may 
not  be  present  if  the  subarachnoid  space  above  the  opening  be  so 
<)1)hti'U('ted  that  free  communication  with  the  subarachnoid  space 
above  is  interrupted.  In  addition  to  the  presence  or  absence  of  pul- 
sation, the  ojjerator  informs  himself  as  to  the  degree  of  tension  of 
the  cerebrospinal  fluid,  and  as  to  whether  the  cerebrospinal  fluid  be 
excessive ;  he  notes  whether  the  excess  of  fluid  be  evenly  distributed 


240  WAR    SUEGEEY    OF    THE    ISTEEVOIIS    SYSTEM. 

or  circumscribed  as  in  circumscribed  serous  meningitis.  In  the  case 
of  intradural  tumor  an  excess  of  fluid  is  found  usually  above  the 
tumor,  though  occasionally  below,  but  in  either  case  the  fluid  may  be 
under  such  tension  that  not  the  slightest  pulsation  can  be  detected. 
Once  the  subarachnoid  space  is  open  the  cerebrospinal  fluid  escapes 
under  varying  degrees  of  tension.  Through  the  initial  puncture  of 
the  arachnoid  I  have  seen  the  fluid  spurt  into  the  operator's  face. 

The  importance  of  hemostasis  and  its  means  of  accomplishment 
have  been  discussed,  so  that  it  suffices  at  this  time  to  call  attention  to 
them  merely  by  way  of  emphasis.  The  second  important  injunction, 
the  avoidance  of  trauma,  applies,  of  course,  only  to  the  steps  of  the 
operation  that  have  to  do  with  the  spinal  membranes,  the  roots,  and 
the  cord. 

I  have  been  convinced  of  the  evil  effects  of  trauma  by  many  opera- 
tive experiences,  particularly  those  upon  the  roots.  Not  until  it 
becomes  n-ecessary  to  manipulate  the  roots,  as  in  separating  the  an- 
terior from  the  posterior,  v,dll  any  material  change  be  noted  on  the 
pulse  or  blood  pressure.  The  application  of  a  pledget  of  cotton, 
saturated  with  1  c.  c.  of  0.4  per  cent  stovain,  to  the  cord  and  roots  at 
the  site  of  manipulation  or  just  above  it  has  a  positive  inhibitive 
influence. 

While  I  do  not  believe  the  sudden  escape  of  cerebrospinal  fluid  is 
the  cause  of  spinal  shock,  I  can  readily  see  how  undesirable  it  v,ould 
be  to  allow  the  dural  sac,  ventricles,  and  cisterns  to  be  emptied  of 
their  fluid  contents  during  operation.  The  continuous  flow  of  fluid 
is  prevented  partly  by  arching  the  patient's  back  so  that  the  opening 
in  the  dnra  is  at  the  highest  level  of  the  subarachnoid  space,  but  to 
ke^p  the  field  entirely  dry,  posture  must  be  supplemented  with  small 
tampons  of  cotton  gently  introduced  between  cord  and  dura  just 
above  and  below  the  upper  and  lower  limits  of  the  dural  incision. 
With  this  preparation  the  operator  is  prepared  to  inspect  the  men- 
inges, roots,  and  cord,  and  the  subsequent  steps  of  the  operation 
will  depend  upon  the  nature  of  the  lesion. 

Closure  of  the  wound. — Before  closing  the  dural  wound  hem- 
orrhage must  be  under  absolute  control.  The  presence  of  even  a  small 
amount  of  blood  with  its  fibrin  content  leads  inevitably  to  the  de- 
velopment of  adhesions,  and  though  this  may  not  lead  to  serious  con- 
sequences, every  effort  should  be  made  to  avoid  them  and  to  leave 
the  structures  within  the  sac  as  nearly  free  from  the  effects  of  tra\una 
as  possible.  But  a  freer  hemorrhage  within  the  sac  is  responsible 
unquestionabl}^  for  some  of  the  functional  disturbances,  either  transi- 
tory or  permanent,  that  have  followed  laminectomies.  The  presence 
of  complete  or  partial  paralysis  of  one  or  both  extremities,  or  of 
bladder  or  rectum,  may  be  the  result  of  trauma  incidental  to  traction 
upon  the  cord  or  roots  or  possibly  to  the  resulting  edema,  following 


LAMINECTOMY.  241 

exploratory  laminectomies,  but  the  persistence  of  these  motor  phe- 
nomena should  be  charged  in  most  instances  to  hemorrhage.  Perfect 
hemostasis  is,  therefore,  a  sine  qua  non  in  prepai'ution  for  closure 
of  the  dura.  There  are  occasions  when  with  propriety  the  dural 
incision  may  be  left  unsutured.  Pachymeningitis  hypertrophica 
cervicalis  chronica  and  inopei'able  tumors  are  conditions  in  Avhich 
for  the  relief  of  pressure  it  is  advisable  not  to  suture  the  dura,  and  in 
meningitis  serosa  chronica  there  are  some  who  believe  in  the  advan- 
tages of  providing  for  drainage,  thus  preventing  the  reaccumulation 
of  cerebrospinal  fluid.     With  this  view,  hoAvever,  I  am  not  in  accord. 

To  close  the  dural  incision  a  small,  curved  iris  needle  and  00  silk 
should  be  used.  A  continuous  suture  is  preferable  to  an  interrupted 
suture  as  a  safeguard  against  leakage  and  the  establishment  of  a 
cerebrospinal  fistula.  The  needle  is  introduced  precisely  in  the  edge 
of  the  dural  incision,  the  suture  is  continuous,  and  with  the  wound 
thus  closed,  no  foreign  material  will  be  exposed  within  the  dural  sac 
and  there  can  be  no  leakage  through  the  needle  punctures  and  no 
leakage  along  the  line  of  suture.  Observing  these  details  in  the 
technic  of  dural  suture,  I  have  never  seen  any  escape  of  cerebrospinal 
fluid  after  leminectomies. 

To  obliterate  the  "  dead  space  "  that  remains  after  removal  of  the 
spinous  processes  and  laminae,  three  or  four  splint  sutures,  accord- 
ing to  the  length  of  the  incision,  are  introduced,  and  after  closure 
of  all  the  layers  of  the  wound  is  completed,  one  end  of  the  suture  is 
threaded  through  a  section  of  narrow  rubber  tubing  so  that  when 
tied  the  cuture  will  not  cut  through  the  skin.  The  next  row  of  sutures 
of  continuous  iodin  catgut  brings  the  sheath  and  margins  of  the 
erector  spinales  into  apposition,  and  over  this  the  intervertebral 
fascia  is  brought  into  apposition  with  interrupted  sutures  of  catgut. 
The  intervertebral  fascia  is  a  strong  unyielding  structure  and  un- 
questionably plays  an  important  part  in  preventing  such  incapacity 
as  might  come  from  the  removal  of  the  spines  and  interspinal  liga- 
ments. As  giving  support  to  the  structures  of  the  back  after  laminec- 
tomies, it  plays  a  part  analogous  to  that  of  the  fascia  of  the  external 
oblique  after  operations  in  the  lower  abdomen.  There  remain  to  be 
closed,  the  skin  and  the  superficial  fascia,  which  are  brought  into 
apposition  separately,  the  latter,  with  interrupted  catgut  sutures  and 
the  former  Avith  sutures  of  interrupted  silkworm  gut.  Finally,  the 
splint  sutures  are  tied,  the  skin  again  disinfected  with  iodin  and  the 
dressing  applied. 

After  the  operation. — The  management  of  the  patient  after  a  lami- 
nectomy must  take  into  consideration  various  conditions  that  do  not 
pertain  to  operations  elsewhere.  With  decubitus  already  present,  or 
fr-om  the  nature  of  the  lesion  likely  to  deA^elop,  the  patient  is  placed 
13764—17 16 


242  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

upon  a  water  or  air  mattress.  On  the  bed  immediately  beneath  the 
dressing  I  place  a  square  of  wax  paper  covered  with  sterile  cotton  to 
absorb  any  blood  that  may  ooze  through.  This  is  merely  a  pre- 
cautionary measure.  I  have  never  had  occasion  to  use  fixation  dress- 
ings, either  of  plaster  of  Paris  or  poroplastic  felt.  There  is  no  in- 
dication for  fixation,  except  perhaps  in  the  cervical  region,  where  the 
use  of  small  sand  bags  on  either  side  of  the  head  and  a  strip  of  ad- 
hesive plaster  from  one  to  the  other,  crossing  the  patient's  forehead, 
meets  every  need. 

When  the  operation  has  been  in  the  lumbar  region  the  nurses  and 
attendants  should  be  warned  of  the  risks  of  contamination  of  the 
dressings  with  the  excreta,  and  as  a  protection  the  dressing  should  be 
hermetically  sealed  around  the  edges  as  well  as  over  the  surface  with 
adhesive  plaster.  With  an  incontinent  bladder  either  a  suprapubic 
drain  or  a  permanent  catheter  is  installed,  and  retained  at  least  until 
the  wound  be  healed.  The  wound  itself  requires  little  attention ;  save 
for  the  removal  of  a  drain  at  the  end  of  twenty-four  hours,  the  dress- 
ing is  not  disturbed  until  the  seventh  day  for  the  removal  of  stitches, 
at  which  time  a  protective  pad  is  applied  and  allowed  to  remain  until 
no  further  protection  is  required. 

The  escape  of  cerebrospinal  fluid  after  laminectomies  is  more  or 
less  of  a  hoax.  When  the  dural  wound  is  closed,  as  I  have  directed, 
with  a  continuous  silk  suture  properly  introduced,  no  cerebrospinal 
fluid  will  escape,  and  I  might  even  go  so  far  as  to  say  that  even  when 
I  have  had  to  rem.ove  a  portion  of  the  dura  I  have  had  no  apprehen- 
sion of  a  cerebrospinal  fistula,  since  the  closure  of  the  musculocu- 
taneous wound  with  four  tier  sutures,  one  each  in  the  muscles,  apo- 
neurosis, superficial  fascia  and  skin,  is  an  absolute  guarantee  against 
leakage.  Where  cerebrospinal  fistulse  have  been  established  there  is, 
of  course,  the  danger  of  infection,  and  the  convalescence  will  be  em- 
barrassed with  intense  headache  and  vomiting,  sweating,  hyperpy- 
rexia and  acceleration  of  pulse.  In  some  cases  it  is  reported  the  fis- 
tula closed  spontaneously,  in  some  the  patient  died  of  meningitis. 
To  arrest  the  flow  and  to  favor  spontaneous  closure,  the  foot  of  the 
bed  should  be  elevated  and,  as  a  guard  against  infection,  the  wound 
should  be  cared  for  most  scrupulously. 

The  condition  of  the  patient  after  the  operation  in  many  instances 
is  not  such  as  to  give  alarm.  The  pulse  may  be  accelerated,  the  tem- 
perature subnormal,  and  the  skin  leaky,  but  it  is  unusual  to  see  the 
patient  in  a  condition  even  of  surgical  shock  or  collapse.  In  the 
majority  of  cases,  therefore,  with  the  exception  of  morphine  for  the 
relief  of  pain,  little  or  no  medication  is  required,  and  because  the 
sphincters  are  frequently  paralyzed  and  because  the  dressing  may  be- 
come soiled  by  leakage,  proctoclysis  is  not  to  be  employed. 


LAMINECTOMY.  243 

The  most  constant  and  often  the  only  subjective  clistnrbance  is  pain. 
Whatever  may  be  the  experience  of  others,  I  find  that  most  of  my 
joatients  have  enough  pain  to  require  one  or  more  hypodermics  of 
morphine  chiring  the  first  24  hours.  The  degree  of  pain  will  de- 
pend somewhat  upon  the  nature  of  the  operation,  chiefly  upon  in- 
cidental trauma  of  the  roots;  So  that  after  rhizotomy  or  the  disen- 
tangling of  a  tumor  from  the  roots,  pain  will  be  intense  and  morphine 
or  codein  is  given  just  as  liberally  and  frequently  as  may  be  neces- 
sary to  insure  the  patient's  comfort.  The  effect  of  morphine  upon  the 
pulse  rate  under  these  circumstances  is  striking,  so  that  morphine  is 
just  as  clearly  indicated  as  the  employment  of  general  cardiac  stimu- 
lants are  uncalled  for. 

No  general  rule  can  be  laid  down  as  to  the  period  of  enforced  rest 
in  bed.  The  extent  of  the  laminectomy,  whether  in  the  cervical,  tho- 
racic, or  lumbar  region,  must  be  taken  into  account.  In  a  limited  re- 
section, as  of  three  or  four  cervical  or  thoracic  vertebrae,  I  allow  the 
patient  to  sit  up  at  the  end  of  the  second  week,  but  after  more  ex- 
tensive laminectomies,  especially  in  the  lower  thoracic  and  thoracico- 
lumbar  regions,  the  patient  is  content  to  remain  in  bed  two  weeks 
longer.  In  so  many  instances  the  patient  is  already  paralyzed  before 
the  operation  that  the  question  of  his  becoming  ambulant  depends 
more  upon  the  paralysis  than  upon  how  many  laminae  were  removed. 

Complications. — The  complications  peculiar  to  laminectomj^  are 
chiefly  those  which  arise  from  intentional  or  unintentional,  avoidable 
or  unavoidable,  damage  to  the  cord  and  roots;  that  is,  motor  or  sen- 
sory disturbance,  transitory  or  permanent.  In  the  removal  of  tumors, 
the  displacement  of  the  cord,  the  separation  of  roots,  involves  a  de- 
gree of  trauma  that  may  give  rise  to  temporary  disturbances  of 
function,  more  often  motor  than  sensory.  Thus,  there  maj^  be  com- 
plete or  partial  paralysis  of  one  or  both  low^er  limbs  and  of  bladder 
and  rectum,  abdominal  distention  and  anesthesia  below  the  level 
of  the  operation.  Although  distention  is  a  more  frequent  complica- 
tion of  operation  upon  the  lower  thoracic  vertebrae,  the  abdomen 
becomes  distended,  sometimes  to  such  a  degree  as  to  cause  more  or 
less  respiratory  embarrassment  from  pressure  of  the  distended  bowel 
upon  the  diaphragm.  When,  coupled  with  this,  peristalsis  is  arrested 
and  the  patient  is  unable  to  pass  gas,  the  condition  presents  a  picture 
not  unlike  that  of  peritonitis  minus  tenderness.  Fortunately,  the  dis- 
tention is  of  short  duration,  disappearing  gradually  in  two  or  three 
days,  and  unless  the  patient  be  in  distress  the  condition  may  be  al- 
lowed to  pass  untreated.  In  the  more  exaggerated  forms  I  have 
found  the  use  of  the  rectal  tube  and  1  c.  c.  of  pituitrin  hypodermati- 
cally  offered  the  greatest  measure  of  relief. 

After  laminectomies  there  may  be  either  retention  or  incontinence. 
Retention  of  urine  is  really  quite  common,  irrespective  of  what  may 


244  WAR   SURGEEY   OP    THE    NEEVOUS   SYSTEM. 

have  been  the  condition  of  the  bladder  before  the  operation,  and 
restoration  of  bladder  function  may  be  a  matter  of  days  or  weeks. 
When  of  short  duration,  intermittent  rather  than  permanent  catheteri- 
zation is  preferable,  but  if  after  a  few  days  there  is  no  tendency 
to  immediate  restoration  of  function,  permanent  catheterization  can 
not  be  avoided.  One  can  not  always  rely  upon  the  patient's  sensa- 
tions, as  in  certain  regions,  especially  the  lumbosacral,  the  patient 
is  unconscious  of  the  sense  of  overdistention.  Incontinence  of  urine 
is  a  ver}^  much  more  grave  complication  and  implies  more  serious 
damage  to  cord  or  meninges.  Whether  it  will  be  permanent  or  transi- 
tory may  usually  be  determined  by  the  nature  and  seat  of  the  lesion. 
I  have  seen  a  number  of  cases  of  transitory  retention,  but  only  one 
instance  of  permanent  incontinence. 

Paralysis  of  bladder,  rectum,  or  extremiti'ss,  developing  as  com- 
plications after  operations  within  the  dural  sac,  wholly  irrespective 
of  what  might  have  been  due  to  the  lesion,  are  unquestionably  the 
expression  of  pressure  within  or  without  the  cord,  and  whether  they 
he  transitory  or  permanent  depends  altogether  upon  the  nature  of 
the  cause.  It  has  been  said  by  some  that  an  excessive  collection  of 
cerebrospinal  fluid  may  be  held  responsible  for  the  pressure  symp- 
toms. This  seems  to  me  possible  but  unlikely.  I  believe  the  most 
-common  cause  is  hemorrhage  without  the  cord  into  the  subarachnoid 
space  or  hemorrhage  and  edema  within  the  cord,  and  depending  upon 
the  extent,  but  more  especially  upon  the  seat,  of  the  hemorrhage,  are 
the  symptoms  transitory  or  permanent.  The  effects  of  a  moderate 
hemorrhage  without  the  cord  into  the  meshes  of  the  arachnoid  would 
hardly  be  more  than  temporar}^ ;  the  same  might  be  said  of  a  transi- 
tory edema  within  the  cord.  But  hemorrhage  within  the  cord  may 
readily  lead  to  permanent  structural  changes  so  extensive  as  to 
cause  a  complete  transverse  lesion.  The  importance,  therefore,  of 
the  avoidance  of  trauma  and  strict  hemostasis  is  again  emphasized. 

Pneumonia  or  hypostatic  congestion  is  a  complication  of  cord 
lesions  rather  than  of  laminectomy,  per  se,  but  it  is  mentioned  at  this 
time  merely  to  suggest  the  propriety  of  elevating  the  patient's  head 
find  trunk  as  a  prophylactic  measure.  This  applies  only  to  cases 
•with  paralysis  of  the  respiratory  muscles,  as  in  cervicothoracic 
lesions. 

The  prevention  of  adhesions  is  a  pertinent  question.  If  for  any 
reason  the  necessity  of  reopening  the  dural  canal  arise,  the  procedure 
wdll  be  devoid  of  difficulty,  providing  there  are  no  intramembranous 
adhesions,  and  the  converse  of  this  may  be  stated  in  more  forceful 
terms.  The  presence  of  adhesions  is  a  very  grievous  obstacle  to  ex- 
ploration. How  to  prevent  them  is,  therefore,  a  vital  question.  To 
deny  the  tendency  for  them  to  form  is  to  close  one's  eyes  to  the  truth, 
and  to  account  for  their  existence  when  reasonable  precautions  are 


LAMINECTOMY.  245 

taken  is  somewhat  baffling.  I  have  given  much  time  and  thought  to 
this  problem,  and,  exchuling  infection,  the  possible  causes  of  ad- 
hesions to  my  mind  may  be  narroAved  down  to  hemorrhage  and 
trauma.  As  for  hemorrhage  the  deposition  of  the  fibrin  in  tlie  blood 
1)etween  the  membranes  in  the  course  of  the  operation  pro\idys  at 
once  a  means  whereby  a  point  or  area  of  adhesion  may  be  formed. 
On  this  account  particularly  must  minute  care  be  taken  to  protect 
the  subdural  sac  from  contamination  with  blood,  and  to  this  end 
bleeding  should  be  controlled  wherever  possible  before  the  dural 
sac  be  opened.  But  there  will  be  more  or  less  uncontrollable  oozing 
to  be  provided  for,  and  to  protect  the  sac  from  this  I  have  suggested 
the  use  of  tampons  of  cotton  laid  one  on  either  side  of  the  dural 
incision,  so  that  when  the  dural  flaps  are  reflected  with  traction 
sutures,  the  cotton  tampons  will  prevent  the  overflow  of  blood  into 
the  dural  sac.  Thus,  it  is  a  comparatively  simple  matter  to  prevent 
the  deposition  of  fibrin  within  the  sac  when  the  source  of  hemor- 
rhage is  extradural.  Not  so,  however,  when  the  hemorrhage  is  sub- 
dural, since  the  necessities  of  the  situation,  the  removal  of  tumors, 
the  cutting  of  roots,  will  provoke  more  or  less  bleeding,  the  control 
of  which  will  tax  the  resources  of  the  operator. 

The  second  source  of  adhesions  is  the  exudate  that  may  form  in 
the  membranes  as  a  result  of  trauma  or  in  the  process  of  repair  of 
the  dural  incision.  The  endothelial  lining  of  the  dura,  like  that  of 
intima  and  peritoneum,  is  so  sensitive  to  the  insult  of  trauma  that 
it  demands  the  greatest  respect. 

The  laminectomized  spine. — There  has  been,  and  still  is,  a  very  preva- 
lent belief — not  among  surgeons,  however — that  the  removal  of 
spines  and  laminae  robs  the  patient  of  the  ability  to  support  the 
weight  of  the  head  or  body  in  greater  or  less  measure,  and  that  after 
laminectomy  the  strength  of  the  back  is  seriously  impaired.  This 
is  an  entire  misconception  of  the  facts.  Necessary  as  the  spines,, 
laminae  or  intraspinal  laminae  might  seem  to  be,  it  is  surprising  how 
little  the  removal  of  these  structures  interferes  with  the  carriage  of 
the  body  at  rest  and  in  motion.  This  general  statement  must  be 
qualified  in  tAvo  particulars,  first,  when  the  structure  of  the  vertebral 
bodies  are  tuberculous  or  the  seat  of  a  malignant  tumor,  the  removal 
of  spines  and  laminae  may  be  a  matter  of  some  consequence  and  call 
for  some  methods  of  artificial  support.  It  has  been  suggested  that 
under  such  circumstances  the  spinous  processes,  laminae  and  artic- 
ular processes  above  and  below  the  defect  may  be  lashed  together 
with  strong  silver  wire.  I  have  never  had  occasion  to  adopt  this 
suggestion,  practical  as  it  seems,  and  would  hesitate  to  do  so  be- 
cause of  the  possible  complications  of  wound  repair.  Theoretically, 
the  demands  for  this  method  of  giving  greater  security  to  the 
spine  are  not  very  great;  if  the  indication  be  of  malignant  dise^^s"-. 


246  WAR    SUEGERY   OF    THE    NERVOUS   SYSTEM. 

of  the  vertebral  bodies,  a  spinal  brace  would  answer  the  purpose 
quite  as  well  for  the  time  that  remains  until  the  patient  becomes 
bedridden,  and  if  the  indication  be  of  tuberculous  spondylitis,  the 
lesion  itself  would  necessitate  the  use  of  a  brace  or  some  other  fixa- 
tion appliance.  Secondly,  the  restoration  of  function  in  the 
laminectomized  spine  will  be  influenced,  not  by  the  number  of  spines 
removed  but  by  their  location.  The  only  disability  that  has  been 
brought  to  my  attention  was  after  the  removal  of  the  laminse  of 
five  lumbar  vertebrae.  One  of  my  patients,  a  middle-aged  man, 
suffered  more  or  less  discomfort  in  the  form  of  pain  on  certain 
movements  and  a  feeling  of  lack  of  support.  Naturally  there  is 
more  strain  at  the  lumbosacral  junction  than  elsewhere,  not  only 
because  it  is  at  the  base  of  the  spine  and  supports  the  entire  body, 
but  because  this  is  the  junction  between  a  movable  and  a  fixed  point 
in  the  vertebral  column,  a  point  which  of  necessity  is  subjected  to 
greater  strain. 

Leaving  out  of  consideration,  therefore,  laminectomies  at  the 
lumbosacral  junction  and  in  the  presence  of  softened  vertebral 
bodies,  we  now  have  no  hesitation  in  removing  as  many  consecutive 
spines  and  laminse  as  may  be  required  for  thorough  exploration  or 
for  adequate  dealing  with  the  lesion  itself.  The  osteoplastic  flap 
is'  not  essential  to  the  maintenance  of  function,  but  perfect  apposi- 
tion of  the  several  musculo-aponeurotic  layers  in  the  closure  of  the 
wound  plays  a  very  important  part. 


Paiit  7. 

ABSTRACTS  FROM  THE  ENGLISH,  GERMAN,  AND  FRENCH 
LITERATURE  ON  SPINAL  INJURIES  IN  WAR. 

It  is  difficult  to  determine  the  reason,  but  it  is  nevertheless  a  fact, 
that  the  war  literature  of  injuries  to  the  spine  and  cord  is  noticeably 
less  than  that  devoted  to  the  skull  and  brain ;  so  much  less  indeed, 
as  to  be  almost  scant_y.  Holmes  ventures  as  an  explanation,  the  fact 
that  a  large  proportion  of  the  cases  of  spinal  injury  die  soon  after 
the  infliction  of  the  injury  on  account  of  shock,  plus  associated 
wounds  of  chest  and  abdomen.  At  all  events,  the  literature  devoted 
to  spinal  injuries  is  almost  scanty. 

For  this  reason  then,  as  well  as  for  the  added  reason  that  there  is 
no  marked  diversity  in  the  opinions  of  the  various  authors,  it  does 
not  seem  wise  to  group  the  extracts  according  to  nationality. 

Fortunately,  the  subject  of  spinal  injury  has  been  studied  most 
intensively,  in  particular  by  Holmes  and  Collier.  The  contributions 
b}^  both  these  investigators  have  been  so  striking  that  we  are  im- 
pelled to  submit  unusually  full  abstracts.  A  careful  mastery  of  these 
abstracts,  or  better  still,  of  the  original  articles,  will  furnish  all  the 
basis  necessary  to  handle  this  type  of  injury  in  accordance  with  most 
modern  principles,  ill  defined  and  poorly  understood  as  these  prin- 
ciples only  too  often  afe. 

Gordon  Holmes:  Spinal  Injuries  of  Warfare.    Brit.  Med.  Jour.,  Vol. 
11,  1915.    Nov.  27,  Dec.  4,  Dec.  11. 

I.  THE  PATHOLOGY  OF  ACUTE  SPINAL  INJURIES. 

The  spinal  cord  may  be  injured  directly  by  the  projectile 
and  either  completely  or  incompleteh^  divided,  but  more 
commonly  it  escapes  direct  damage  by  the  missile  and  is 
injured  only  by  displaced  fragments  of  bone,  which  either 
compress  or  lacerate  it;  frequently,  however,  it  is  not  injured 
directly  either  by  the  projectile  or  by  indriven  fragments 
of  bone,  and  the  structural  changes  in  such  cases  can  be 
attributed  only  to  the  concussion  or  commotion  effects  pro- 
duced in  the  cord  by  a  missile  which  has  struck  some  portion 
of  a  vertebra.  Spinal  concussion  is  most  commonly  seen 
when  the  projectile  has  touched  either  a  spinous  or  trans- 
verse process,  which  it  may  have  fractured  or  not,  but  it 
may  be  also  produced  by  a  bullet  which  penetrates  or  per- 
forates the  body  of  a  vertebra. 

247 


248  WAE   SUEGERY   OF    THE    NERVOUS   SYSTEM. 


DIRECT    INJURIES. 


On  examining  a  case  in  which  the  spinal  cord  has  been 
completely  divided,  we  find  as  a  rule  a  considerable  amount 
of  clot  and  often  pieces  of  bone  between  its  two  ends.  A 
few  days  after  the  infliction  of  the  wound  these  are  swollen, 
irregular,  and  very  soft  to  touch  for  at  least  1  cm.  from  the 
point  of  division ;  indeed  they  may  be  more  or  less  diffluent, 
and  on  handling  semifluid  disintegrated  material,  frequently 
stained  with  blood,  wdiich  Sir  George  Makins,  from  his 
experiences  in  the  South  African  War,  very  accurately  de- 
scribed as  custard-like,  may  extrude.  After  hardening  these 
portions  still  seem  swollen,  softened,  and  oedematous;  the 
outlines  and  details  of  their  cross  section  are  obscured,  and 
there  are  often  minute  or  larger  hemorrhages  within  them, 
chiefly  in  the  gray  matter. 

Not  infrequently  the  spinal  wound  is  infected,  but  these 
appearances  are  then  modified  only  by  the  existence  of  a 
septic  meningitis  which  may  spread  rapidly  upward  and 
downward  from  the  lesion.  It  occasionally  happens,  how- 
ever, that  hemorrhages  and  early  adhesions  betAveen  the 
arachnoid  and  dura,  and  in  the  subarachnoid  space  limit 
the  infection  to  the  wound.  Subdural  hemorrhages  of  con- 
siderable size  also  occur,  but  they  are  rarely  sufficiently 
large  to  compress  the  spinal  cord.  Hemorrhages,  which 
are,  how^ever,  generally  small  and  insignificant,  are  more 
commion  in  the  soft  meninges. 

Microscopical  examination  ahvays  shows  that  there  are 
severe  and  relatively  extensive  changes  in  the  spinal  cord 
immediately  above  and  below  the  lesion;  for  the  distance 
of  half  a  segment  at  least  and  often  further  the  tissue  is 
completely  softened  and  none  of  its  normal  elements  are 
recognizable. 

These  secondary  changes,  which  occur  in  the  neighbor- 
hood of  a  laceration  or  cli vision  of  the  cord,  evidently 
producQ  further  destruction  of  it.  They  are  obviously 
degenerative  rather  than  inflammatory,  and  are  due  to  the 
edema  and  circulatory  disturbances  that  occur  in  the 
bruised  and  necrotic  tissue  on  the  borders  of  the  injuiy, 
spreading  into  and  involving  parts  which  Avere  not  directly 
damaged  by  the  missile.  Edema  is  the  most  important 
factor;  it  seems  to  affect  the  vitality  and  the  neuroglial 
matrix  as  well  as  of  the  nerve  cells  and  fibers,  and  com- 
bined with  circulatory  disturbances  leads  to  their  disinte- 
gration. 

Distant  lesions. — Edema  of  both  gi'ay  and  white  matter 
with  some  SAvelling  and  softening  of  the  cord  is  the  most  con- 
stant of  these  changes.  It  gradually'  diminishes  away  from 
the  wound  and  often  seems  to  bear  no  definite  relation  to 
its  severity. 

Hemorrhages  of  various  sizes  are  often  aisociat^d  with 
it,  but  these  are  less  constant ;  they  are  generallj^  small  punc- 
tiform  extravasations  of  blood,  which  give  a  mott^r^d  appear- 
ance to  the  cross  section  of  the  cord,  but  thev  ~^'p  frfouentlv 


FOREIGN    WAR    LITERATURE.  249 

larger;  a  large  central  hemorrhage  with  a  tendency  to 
spread  longitudinally  in  the  cord,  such  as  is  generally  un- 
derstood by  the  term  '"  hannatomyelia,"  was  not  present  in 
any  of  the  fifteen  cases  in  which  the  microscopical  exami- 
nation has  been  completed.  These  hemorrhages  are  found 
particularly  in  the  gray  matter  and  about  the  central  canal; 
one  of  the  most  common  sites  is  the  dorsal  horn,  where  they 
can  obviously  interrupt  the  reception  of  afferent  impulses. 
In  the  gray  matter  they  are  liable  to  break  up  and  destroy 
the  tissue,  but  when  small  they  produce  surprisingly  little 
change  in  the  Avhite  columns,  the  extravasated  cells  merely 
tracking  along  the  vessels  or  betw^een  the  fibers;  occasion- 
ally, however,  there  is  some  local  softening,  and  later  neu- 
roglial proliferation,  around  larger  extravasations. 

The  extent  of  these  small  disseminated  intraspinal  hem- 
orrhages is  occasionally  surprising;  in  one  case  they  spread 
oyer  two  and  a  half  segments  on  each  side  of  the^  wound. 
They  are  found  with  lesions  of  all  regions  of  the  cord,  but 
they  are  usually  most  prominent  when  the  cervical  region 
is  wounded  and  probably  least  so  with  injuries  of  the  lower 
dorsal  and  lumbar  segments.  Owing  to  the  relatively  slight 
destruction  they  produce  in  the  tissues  their  importance  in 
the  production  of  clinical  symptoms  may  be  easily  over- 
estimated. 

CONTUSION  OR  COMPRESSION   OF  THE   SPINAL   CORD. 

When  a  portion  of  a  vertebra  or  a  detached  spicule  of  bone 
is  driven  into  the  spinal  canal  it  frequently  lacerates  both 
the  cord  and  the  theca  and  causes  lesions  which  may  differ 
only  in  degree  from  those  produced  directly  by  a  projectile. 
Frequently,  however,  there  is  no  obvious  external  injury  to 
the  cord  and  the  dura  mater  is  not  torn,  even  though  the 
clinical  symptoms  indicated  a  complete  transverse  lesion. 
Small  hemorrhages  into  the  meninges  are,  however,  common, 
and  on  palpation  the  cord  at  the  level  of  the  contusion  is 
soft,  and  if  the  pia  mater  is  incised  or  pricked  semifluid 
custardlike  material  may  escape. 

When  the  injury  is  less  severe  the  normal  appearance  of 
the  cross  section  is  only  obscured,  and  there  are  frequently 
minute  hemorrhages  throughout  it.  The  damaged  arek 
and  the  segments  on  either  side  of  it  a,re  usually  swollen  by 
edema,  and  the  cord  may  be  indented  by  the  indriven  bone. 
When  the  lesion  is  examined  under  the"  microscope  changes 
are  found  very  similar  to  those  in  the  parts  adjoining  a 
direct  injury,  but  their  intensity  naturally  varies  much. 
The  most  important  is  softening  "and  disintegration  of  the 
tissues,  always  greatest  in  the  region  whiclT  was  directly 
contused.  If  the  injury  is  severe  the  wdiole  cross  section  may 
be  softened,  but  more  commonly  there  are  discontinuous  foci 
in  the  ventrolateral  and  dorsal  columns.  The  gray  matter 
may  be  also  completely  destroyed  in  whole  or  parts,'^but  it  is 
more  usually  extremely  edematous  and  only  partly  disinte- 


250  WAE    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 

grated,  with  its  nerve  cells  necrotic  or  in  advanced  chroma- 
tolysis.  Occasionally  onl}''  a  diffuse  or  focal  necrosis  is 
found  in  which  no  stainable  elements  persist.  The  affected 
areas  are  gradually  invaded  by  granule  cells,  and  a  consid- 
erable proliferation  of  neuroglial  cells  is  visible  around 
them,  but.  apart  from  a  pronounced  congestion  of  the  vessels 
and  an  occasional  increase  of  the  cells  in  their  walls,  there 
is  no  evidence  of  any  inflammatory  process.  The  amount 
of  hemorrhages  into  the  injured  region  also  varies  vary 
much. 

The  distant  lesions  differ  in  no  respect  from  those  which 
are  so  commonly  associated  with  direct  spinal  injuries. 
Diffuse  foci  of  necrosis  and  softening,  vacuolation  due  to 
falling  out  of  fibers  and  the  sievelike  rarefaction  produced 
by  the  disappearance  of  fibers  and  of  the  finer  glial  matrix, 
as  well  as  minute  scattered  hemorrhages,  are  found  in  the 
white  matter  of  the  adjoining  segments,  while  the  gray 
matter  is  also  edematous,  and  contains  similar  hemorrhages 
and  perhaps  foci  of  softening.  The  central  cylindrical 
cavities,  which  have  been  already  described,  also  occurred 
in  the  dorsal  columns  relatively  as  frequently  as  with  direct 
injuries. 

CONCUSSION    OF    THE    SPINAL    CORD. 

In  cases  of  concussion,  when  the  cord  is  not  damaged  by 
the  fracture  or  dislocation  of  a  vertebra,  there  may  be  no 
external  signs  of  injury,  or  only  a  more  or  less  uniform 
swelling  opposite  the  site  of  impact,  and.  even  to  touch,  no 
definite  abnormality  may  be  recognizable. 

On  microscopical  examination  the  vessels  are  found  en- 
gorged, and  there  are  generally  punctiform  hemorrhages, 
especially  in  the  gray  matter.  The  most  striking  change, 
however,"^  is  the  cedematous  swelling  of  the  most  affected  seg- 
ments with  either  diffuse  or  focal  necrosis  and  softening, 
which,  at  least  in  the  cases  that  have  been  examined  micro- 
scopically, has  been  most  pronounced  in  that  part  of  the 
cross  section  nearest  the  point  of  impact.  In  these  areas 
there  may  be  complete  destruction  of  all  the  functional  ele- 
ments, but  more  usually  only  a  proportion  of  the  fibers  have 
disappeared,  while  the  myeline  sheaths  and  axis  cylinders  of 
others  are  swollen.  Focal  softenings  also  occur  in  the  gray 
matter,  but  are  usually  unrelated  to  the  hemorrhages  which 
this  frequently  contains.  There  is,  often,  however,  some 
softening  and  disintegration  of  the  tissue,  as  well  as  degen- 
eration of  the  nerve  cells,  around  these  hemorrhages. 

The  distant  lesions  in  cases  of  concussion  are  similar  to 
those  found  associated  with  direct  and  contusion  injuries, 
but  they  are  often  very  marked  in  relation  to  the  changes 
found  at  the  site  of  maximum  damage.  Scattered  hemor- 
rhages, irregular  foci  of  necrosis,  and  softening  and  cavity 
formation  occur,  but  the  most  pronounced  feature  is  the  ex- 
tensive parenchymatous  changes  that  often  extend  over  four 
or  five  segments  in  either  direction.     These  consist  in  the 


FOREIGN   WAE    LITERATURE.  251 

swelling  of  fibers,  either  isolated  or  in  groups,  in  the  midst 
of  tissue  which  is  otherwise  normal  or  onlj^  slightly  oedema- 
tous;  as  a  rule  the  axis  cylinder  is  more  swollen  and  the 
myeline  sheath  surrounds  it  as  a  distended  and  attenuated 
ring,  but  in  places  the  sheaths  are  more  affected,  and  are 
often  broken  up.  The  disappearance  of  these  swollen  fibers 
and  the  partial  disintegration  of  the  neuroglia  leave  vacuoles 
and  round  or  oval  cavities  in  the  white  matter  and  give  it  a 
reticular  or  sieve-like  appearance.  There  are  also  often  con- 
siderable histological  alterations,  either  degenerative  or 
chromatolytic,  of  the  nerve  cells  at  some  distance  from  the 
level  of  the  injury,  but  these  are  found  most  commonly  where 
the  tissue  is  cedematous. 

We  must  now  consider  shortly  the  nature  of  these  changes 
which  have  been  described,  the  causes  to  which  they  are  due, 
and  their  significance  in  the  production  of  the  clinical  symp- 
toms that  characterize  these  cases.  The  conclusions  and 
views  expressed  must  not  be  regarded  as  final. 

Spinal  concussion. — The  most  important  and  obscure  fac- 
tor is  that  which  we  understand  by  concussion — that  is,  func- 
tional or  anatomical  disturbances  produced  indirectly  in  the 
spinal  cord  by  a  sudden  and  violent  impact  on  the  vertebral 
column.  The  nature  of  spinal  concussion  has  been  much  dis- 
cussed, and  it  has  been,  in  fact,  questioned  if  spinal  lesions, 
such  as  those  described  above,  do  occur  apart  from  tempo- 
rary dislocation  or  fracture  of  a  vertebra,  compression  by 
fragments  of  bone,  or  an  extra  or  subdural  hemorrhage 
causing  direct  trauma  to  the  cord. 

But  many  cases  in  wh^ch  none  of  these  possible  causes 
exist'^d  have  been  recorded,  and  Ave  have  had  the  opportu- 
nity of  observing  cases  in  which  they  could  not  be  demon- 
strated. Further,  certain  of  the  distant  lesions  that  we  have 
already  described,  which  often  extend  over  several  segments 
en  either  side  of  the  primary  injury,  or  beyond  the  level  of 
the  mipact  on  the  vertebral  column,  can  not  be  due  solely  to 
a  direct  trauma,  and  they  are  identical  in  nature  to  those  at- 
tributed to  concussion.  The  changes  are  irregular  focal 
softenings  or  patches  of  necrosis,  sieve-like  vacuolation  of 
the  white  matter  disseminated  hemorrhages  and  local  lesions 
of  the  myelinated  fibers. 

It  is  in  the  first  place  necessary  to  insist  that  these  changes 
are  not,  as  oedema  may  be,  continuous  with  those  m  the 
neighborhood  of  the  spinal  wound ;  the  hemorrhages,  for  in- 
stance, are  usually  discrete  and  are  often  only  minute  ex- 
travasations of  blood  in  the  Virchow-Eobin  or  perivascular 
spaces,  while  the  focal  necroses  and  softenings  do  not,  as  a 
rule,  spread  longitudinally  in  the  cord  from  the  region  of 
the  tniuma.  Further,  when  a  group  of  fibers  is  alffected. 
the  lesion  is  usually  focal,  and  it  is  not  necessarily  those  of 
one  ti-act  only  that  are  involved ;  it  can  not,  consequently,  be 
either  a  manifestation  of  a  secondary  degeneration  or  of  a 
pathological  change  wdiich  has  spread  from  the  point  at 
Avhich  the  fibers  were  directly  injured. 


252  WAR   SURGEEY   OF    THE    NERVOUS   SYSTEM, 

The  special  character  of  these  lesions  is,  therefore,  their 
diffuse  and  iiTegiilar  distribution  and  their  tendency  to 
diminish  gradually  from  the  point  of  maximal  disturbance. 
They  are  not  due  to  hemorrhages,  as  these  bear  no  constant 
lylaition  to  them,  and  as  vascular  occuisions  are  also  rare, 
these  obviously  can  not  be  the  main  causal  factor.  On  the 
other  hand,  as  the  chief  lesions  are  foci  of  primary  necrosis 
and  parenchjmiatous  change  in  the  cells  and  nerve  fibers,  the 
essential  changes  m.ay  be  described  as  primary  disturbances 
in  the  vitality  of  certain  portions  of  the  tissue,  associated 
with  oedema  and  frequently  with  small  scattered  hemor- 
rhages. 

It  is  difficult  to  offer  a  complete  and  satisfactory  explana- 
tion of  how  a  blow  on  the  vertebral  column  can  produce 
these  lesions  in  the  cord,  protected  as  it  is  within  the  canal. 
Certain  structural  alterations  found  in  cerebral  concussion 
are  attributed  to  the  violent  oscilla^tions  produced  in  the  cere- 
brospinal fluid,  especially  in  that  of  the  ventricles,  but  the 
spinal  cord  is  only  surrounded  by  fluid,  and  is  able  to  swing 
to  some  extent  within  the  dural  sac  with  its  oscillations. 
The  waA'CS  of  pressure  thus  set  up  may,  however,  produce 
physical  effects  within  the  cord,  and  possibly  disturbance 
of  its  lymph  circulation,  but  the  most  probable  explanation 
is  that  put  forward  by  Fielder,  according  to  which  the  cord 
is  made  to  oscillate  within  the  canal  by  the  impact  on  the 
vertebral  column,  and  as  its  movements  will  obviously  not 
be  synchronous  with  those  of  the  column  it  may  be  directly 
bruised  against  the  walls  of  the  canal,  while  at  the  same  time 
the  sudden  jarring  of  the  cord  produces  a  physical  disturb- 
ance in  its  tissues,  and  especially  in  the  fluid  axoplasm  of  its 
fibers.  There  is  much  in  favor  of  this  explanation,  and  the 
factors  it  hypothecates  can  not  be  neglected.  The  histo- 
logical changes  in  the  spinal  roots  may  be,  in  fact,  partly  due 
to  the  strain  thrown  upon  them  by  the  displacement  of  the 
cord.  But  if  it  is  the  whole  explanation,  the  structural 
lesions  should  be  greatest  at  the  position  of  contre  coup; 
we  have,  however,  so  far  always  found  them  most  pro- 
nounced immediately  under  the  site  of  impact.  Further, 
it  must  be  remembered  that  the  spinal  roots  and  the  ligamen- 
tum  denticulatum  limit  the  movement  of  the  cord  within  the 
canal,  and  in  many  levels  at  least  must  make  contre  coup 
bw.ising  impossible. 

Wha  ever  may  be  the  exact  mechanism  of  spinal  concus- 
r  i;  n.  it  must  be  admitted  that  a  sudden  violent  impact  on  the 
'  rrtebral  column  can  produce  diffuse,  irregular,  and  severe 
pt-rcfu^'al    changes   within   the   spinal    cord.     The    factors 

h'ch  d'^.termine  the  severity  of  these  lesions  must  be  the 
rnon'"^n<^um  of  the  projectile,  the  part  and  surface  area  of  the 
-  ^ - 'ebra  which  it  strikes,  and  the  region  of  the  spine  which  is 

V.-.   -..^Vlor1. 

Secondary  changes. — Finally  we  must  consider  the  sec- 
ha,iges  which  may  occur  in  the  neighborhood  of 
ry  Injury  and  in  those  portions  of  the  cord  which 
"'   '^d  from  concussion. 


FOREIGN    WAR    LITERATURE.  253 

It  has  occasionally  happened  that  when  the  wound  is  not 
severe  the  patient  was  at  first  able  to  perform  some  move- 
ments in  his  legs,  but  lost  the  power  to  do  so  within  the  fol- 
lowing two  or  three  days.  Further,  we  have  seen  new 
symptoms  develop  or  their  level  alter  under  observation. 
This  may  be  due  to  a  secondary  hemorrhage  into  the  af- 
fected tissues  or  to  progressive  softening,  of  both  of  which 
we  found  possible  evidence  in  our  sections. 

But  the  most  striking  secondar}^  change  was  the  develop- 
ment of  the  cylindrical  cavities  we  have  described.  Their 
exact  i^athogenesis  is  obscure,  but  certain  features  they  pre- 
sent must  be  emphasized  in  attempting  an  explanation.  In 
the  first  place,  they  seem  to  involve  the  destruction  of  very 
little  tissue,  but,  rather,  separate  and  compress  the  fibers 
around  them;  their  contents  must  be  consequently  under 
much  pressure.  In  the  second  place,  they  evidently  de- 
velop away  from  the  lesion,  as  the  material  they  contain  is 
always  less  necrotic  at  their  upper  or  lower  end' if  they  are, 
respectively,  ascending  or  descending  cavities:  and  finally 
they  do  not  as  a  rule  extend  to  the  maximal  lesion,  but  are 
generally  connected  with  this  by  a  track  of  cedematous  or 
softened  tissue,  or  by  a  narrow  channel  of  softening,  or  by  a 
fissure.  It  seeins,  therefore,  probable  that  they  originate 
from  the  accumulation  under  pressure  of  transuded  fluid 
and  degeneration  products  in  a  small  projection  of  the  pri- 
mary lesion,  which  tracks  upwards  or  downwards  along  the 
lines  of  least  resistance  through  either  normal  or  cedematous 
parts,  destroying  only  a  rela'tively  small  amount  of  tissue, 
but  increasing  in  size  probably  under  the  same  principles 
as  a  retention  cyst.  The  granule  cells  which  frequently  line 
their  walls  or  are  contained  within  them  must  be  due  to  a 
reactionary  proliferation  of  the  neuroglia  in  the  tissue 
through  which  they  track. 

Finally,  it  must  be  emphasized  that  they  are  not  due  to 
infection,  as  in  several  cases  in  which  they  occurred  the 
theca  had  not  been  lacerated  and  there  was  no  sign  of  infec- 
tion in  either  the  cord  or  the  meninges. 

They  are  obviously  not  produced  by  hemorrhages,  though 
a  certain  number  of  red  blood  cells' may  be  found  witliin 
them,  nor  by  vascular  lesions,  as  there  has  been  no  evidence 
of  these,  and  the  position  of  the  cavities  does  not  correspond 
with  the  distribution  of  any  spinal  vessel.  The  frequency 
with  which  they  occupy  the  ventral  portion  of  one  or  both 
dorsal  columns  is  striking,  but  its  significance  is  not  clear. 
This  region  is,  however,  a  watershed  area  between  the  distri- 
bution of  the  anterior  spinal  arteries  and  of  the  small 
arteries  that  supply  the  dorsal  columns,  and  as  such  may 
have  a  relatively  poorer  blood  supply  than  other  parts  of 
the  cord.  In  many  cases,  too,  the  dorsal  columns  seem  to 
suffer  more  severely  with  oedema  and  softening  than  the 
ventrolateral  columns. 

It  is  obvious  that  these  irregular  and  diffuse  changes 
Avhich  are  found  in  various  types  of  spinal  injury  mustbe 
taken  into  account  in  interpreting  and  estimating  the  sig- 


254  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

nificance  of  the  clinical  symptoms  that  are  observed  in  these 
cases.     The  following  conclusions  at  least  can  be  clraAvn : 

1.  The  structural  lesions  in  the  spinal  injuries  of  warfare 
are  rarely  sharply  limited  or  circumscribed,  and  can  not  be 
compared  to  those  produced  experimentally  in  a  physio- 
logical laboratory.  The  level  of  the  lesion,  as  indicated 
by  the  clinical  symptoms,  for  instance,  often  does  not  corre- 
spond with  the  level  of  maximal  damage. 

2.  The  lesions  are  so  irregular  in  distribution  and  severity 
Avhen  the  spinal  injury  is  not  complete  that  much  care  is 
necessary  in  drawing  conclusions  from  the  clinical  symp- 
toms alone  on  the  functions  of  parts  which  it  may  be  as- 
sumed have  been  involved. 

3.  Secondary  changes  may  occur  later  in  the  cord  Avhich 
can  alter  or  modify  the  clinical  symptoms. 

II.  THE  CLINICAL  SYMPTOMS  OF  GUNSHOT  INJURIES  OF 

THE  SPINE. 

LOCALIZATION  OF  THE  LESION. 

The  segmental  level  of  the  lesion  can  be  usually  recog- 
nized as  accurately  by  the  extent  of  the  motor  paralysis  as 
by  the  upper  border  of  the  sensory  disturbance;  and  since 
the  evidence  it  gives  is  less  equivocal  and  as  easily  inter- 
preted in  both  military  and  civil  practice,  some  emphasis 
may  be  laid  on  its  importance.  The  segmental  innervation 
of  most  of  the  muscles  of  the  upper  and  lower  limbs  is  now" 
known,  and  this  knowledge  has  been  applied  in  clinical  work, 
A  paralysis  of  all  the  movements  of  the  wrist  and  fingers 
as  well  as  of  the  triceps,  while  the  biceps  remain  strong  or 
only  slightly  weakened,  is  usually,  for  instance,  taken  as 
an  indication  of  a  lesion  in  the  seventh  cervical  segment, 
but  hitherto  little  attention  has  been  given  to  the  evidence 
of  the  level  afforded  by  the  palsy  of  the  trunk  muscles. 
When,  however,  one  of  the  lower  six  dorsal  segments  is  in- 
volvecl,  the  part  and  the  extent  of  the  muscles  of  the  anterior 
abdominal  wall  which  are  paralyzed  form  an  easy  and  cer- 
tain guide  to  the  segment  in  which  the  lesion  lies.  If,  for 
instance,  the  eleventh  is  involved  the  whole  rectus  abdominis 
contracts  when  the  patient  raises  his  head,  attempts  to  sit 
up,  or  coughs,  but  the  iliac  regions  bulge  owing  to  paralysis 
of  the  lower  portion  of  the  obliqui  abdominis,  and  their 
failure  to  contract  can  be  easily  recognized  by  the  observer's 
fingers.  Similarly,  if  the  ninth  segment  is  injured,  it  is  ob- 
vious to  the  finger  that  the  recti  abdominis  dowmwards  from 
about  1  inch  above  the  umbilicus  do  not  contract,  but  are, 
in  fact,  passively  stretched  by  the  tension  produced  on  them 
by  the  shortening  of  the  upper  segments.  Owing  to  the  same 
fact  the  umbilicus,  as  Beevor  first  pointed  out,  rises  toward 
the  xiphoid.  The  state  of  the  intercostals  is  an  equally 
reliable  guide  to  the  level  of  the  injury,  and  permits  a  local 
diagnosis  in  the  upper  as  well  as  in  the  lower  dorsal  seg- 
ments.   If  the  fingers  are  firmly  placed  in  series  on  the  inter- 


FOEEIGN    WAR    LITERATURE.  255 

costal  spaces,  the  unaffected  muscles  are  felt  contracting  on 
each  deep  inspiration,  and  form  a  firm  shallow  floor  to  the 
space,  while  in  paralyzed  spaces  no  contraction  can  be  felt, 
and  on  deep  inspiration  the  finger  sinks  deeper  between  the 
ribs;  in  lean  subjects  this  may  be,  in  fact,  visible  to  the  eye. 
As  the  intercostal  muscles  have  only  unisegmental  innerva- 
tion and  as  each  receives  its  nerve  supply  from  the  corre- 
spondingly numbered  dorsal  root,  the  highest  space  which  is 
paralyzed  indicates  the  level  of  the  spinal  injury. 

The  upper  limit  of  disturbance  of  sensation  is  the  means 
most  commonly  used  in  civil  practice  to  determine  the  seg- 
mental level  of  the  spinal  lesion,  and  if  proper  care  is  taken 
the  evidence  it  gives  is  reliable,  but,  as  we  shall  see  later,  in 
incomplete  lesions,  and  more  especially  in  those  which  are 
Avholly  or  chiefly  unilateral,  errors  may  easily  occur,  and  an 
exact  local  diagnosis  may  not  be  always  possible  from  even 
an  accurate  sensory  chart;  this  is  due* to  the  oblique  course 
of  the  decussating  sensory  fibers  in  the  cord.  In  a  com- 
plete or  very  severe  lesion,  light  contacts  are  usuallv  felt  a 
short  distance  below  the  limit  of  complete  analgesia,  but 
there  is  frequently  some  disturbance  in  tactile  sensibility 
above  the  level  of  the  latter.  The  appreciation  of  moder- 
ate temperature  is  often  lost  slightly  higher  than  that  of 
painful  stimuli. 

The  disturbance  in  the  appreciation  of  vibration  may 
be  also  a  valuable  indication  of  the  leA^el  of  the  injury, 
especially  in  incomplete  cases  in, which  the  dorsal  columns 
only  are  damaged  and  sensibility  to  touch  and  pain  is  un- 
affected, since  the  vibrations  of  a  heavy  tuning  fork  can 
not  then  be  recognized  below  the  corresponding  sesmental 
area.  This  can  be  determined  by  drawing  the  base  of  the 
vibrating  fork  upward  over  the'  soft  parts.  This  method 
is  particularly  valuable  on  the  trunk  when  the  state  of  the 
other  elements  of  sensation  conducted  through  the  dorsal 
colunms  can  not  be  investigated;  the  base  of  "the  fork  may 
be  simply  drawn  over  the  anterior  abdominal  wall  till  the 
level  is  reached  at  which  the  patient  feels  the  vibrations, 
but.  as  the  thorax  can  act  as  a  sounding  box  and  transmit 
the  vibration  widely  over  it,  it  is  necessary  to  apply  the 
fork  here  only  to  folds  of  skin  raised  gently  between  the 
observer's  fingers  and  thumb. 

When  one  of  the  lower  abdominal  segments  is  involved, 
the  level  of  the  lesion  may  be  also  accurately  determined 
by  observing  the  segment  below  which  the  abdominal  cu- 
taneous reflexes  can  not  be  obtained. 

It  must  be  remembered,  however,  that  the  lesions  pro- 
duced directly  or  indirectly  in  the  spinal  cord  by  a  gunshot 
wound  are  often  very  extensive,  and  that  a  clinical  exami- 
nation can,  as  a  rule,  indicate  only  their  oral  limit. 

REFLEXES  AND  REFLEX  TONE. 

In  all  severe  lesions  the  lower  limbs  are  found  flaccid  at 
least  as  early  as  one  day  after  the  infliction  of  the  wound, 


256  WAR   SURGERY   OF    THE    NERVOUS    SYSTEM. 

and  within  three  or  four  days  their  muscles  become  tone- 
less and  flabby;  if  the  lesion  is  complete  or  almost  so  they 
remain  flaccid  and  waste  gradually;  later  the  atrophied 
muscles,  especially  those  of  the  calf  and  the  flexors  of  the 
toes,  undergo  fibrous  contracture.  In  less  severe  cases  the 
muscles  regain  tone  and  the  limbs  become  slightly  rigid, 
generally  within  14  to  20  days.  In  one  case,  however,  we 
observed  slight  rigidity  in  a  limb  five  days  after  the  wound 
was  inflicted,  but  in  another  spasticity  appeared  only  after 
84  days.  In  slight  cases  there  may  be  no  obvious  defect 
of  muscle  tone,  or,  if  diminished,  as  it  frequently  is  at  first, 
it  rapidly  recovers. 

In  those  cases  in  which  some  rigidity  develops  early 
reflex  spasms  of  the  legs  of  the  flexor  type  are  apt  to  occur ; 
they  are,  as  a  rule,  seen  only  a  few  days  after  the  limbs 
have  become  somewhat  spastic,  but  we  have  observed  them 
occasionally  as  early  as  the  sixth  to  tenth  day,  when  the 
tone  of  the  muscles  was  not  yet  exaggerated. 

In  one  interesting  group  in  which  pains  due  to  higher 
spinal  lesions  occur  in  the  legs,  these  limbs  are  often  held 
stiff  and  rigid,  but  careful  examination  shows  that  there 
is  no  true  spasticity,  and  reflex  spasms  do  not  occur;  in 
these  cases  the  spinal  lesion  is  not  severe,  and  voluntary 
movement  is  either  not  lost  or  has  recovered  rapidly. 

The  state  of  the  reflexes  in  the  affected  parts  presents 
interesting  problems.  Except  when  the  spinal  lesion  is 
slight  the  knee  and  ankle  jerks  are  almost  invariably  lost 
at  first,  and  in  severer  cases  remain  absent  during  the 
period  in  which  we  have  been  able  to  observe  them — that 
is,  in  some  instances,  for  as  long  as  6  to  10  weeks.  The 
teaching  of  Dr.  Charlton  Bastian  that  these  reflexes  are  per- 
manently abolished  in  total  transverse  lesions  of  the  cord 
is  generally  accepted  now,  and  our  experience  seems  to 
confirm  it,  though  in  one  case  in  which  a  fragment  of  shell 
casing  lacerated  the  cord  in  the  lower  part  of  the  fourth 
dorsal  segment  and  passed  downward  through  the  next 
three  lower  segments,  apparently  destroying  them  com- 
pletely, feeble  knee  jerks  could  be  obtained  from  the 
fifteenth  day  onward;  whether  or  not  there  was  a  total 
transverse  lesion  has  not  yet  been  determined  by  micro- 
scopical examination. 

In  less  severe  injuries  the  knee  jerks  return,  but  gener- 
ally not  earlier  than  within  two  or  three  weeks;  the  re- 
appearance of  the  ankle  jerks  is  always  later  than  of  the 
knee  jerks,  but  occasionally  ankle  clonus  could  be  obtained 
while  the  knee  jerks  were  still  absent  or  much  depressed. 
In  a  few  cases  in  which  paraplegia  in  flexion  developed 
after  the  return  of  the  knee  jerks  we  saw  these  again  dis- 
appear as  the  flexion  rigidity  increased.  In  lesions  of  the 
upper  four  cervical  segments  the  arm  jerks  are  usually  lost 
at  first,  independently  of  the  severity  of  the  injury,  and 
seem  to  recover  less  early  than  the  knee  jerks. 

Not  only  are  both  knee  and  ankle  jerks  absent  for  a  con- 
siderable time  in  transverse  spinal  injuries,  but  with  uni- 


FOREIGN    WAR  LITERATURE.  257 

lateral  lesions  of  the  cervical  or  dorsal  segments  neither 
can  usually  be  obtained  in  the  paretic  leg  for  some  days, 
or  they  are  at  least  much  diminished  on  this  side  comparecl 
with  the  normal.  The  paretic  leg  is  also  usually  flaccid. 
In  these  cases,  however,  the  reflexes  return  earlier  than  in 
transverse  lesions  of  the  same  degree  of  severity,  but 
usually  not  till  at  least  10  to  12  days  after  the  infliction  of 
the  wound;  in  one  patient  with  a  unilateral  cervical  lesion 
we  could  elicit  only  a  very  feeble  reflex  after  35  days,  and 
it  was  almost  two  months  after  the  injury  that  the  jerks  of 
the  homolateral  limb  were  as  brisk  as  normal. 

On  turning  to  the  superficial  reflexes  we  find  the  abdom- 
inal and  cremasteric  more  easily  abolished  than  the  ten- 
don jerks;  in  fact,  when  the  lesion  lies  above  the  mid- 
dorsal  level,  both  remain  permanently  absent  as  long  as 
there  is  any  obvious  motor  Aveakness  of  the  lower  limbs. 

In  spinal  injuries  above  the  lumbo-sacral  enlargement 
we  would  expect,  on  stimulating  the  sole,  to  obtain  con- 
stantly^ the  abnormal  type  of  pkntar  response  originally 
described  by  Babinski.  When  the  lesion  is  complete  or 
particularly  severe,  however,  no  movement  of  the  toes  may 
result,  and  there  may  be  no  reflex  contraction  of  the  ham- 
strings or  of  other  muscles;  and  this  holds  not  merely  for 
the  first  few  days  when  extensive  functional  disturbances 
might  be  attributed  to  '"  shock,''  but  the  condition  may  per- 
sist for  several  weeks  at  least. 

In  some  cases,  however,  probably  when  the  transverse 
lesion  is  not  total,  stimulation  of  the  sole  produces  only  a 
simple  flexion  of  the  great  toe,  often  associated  with  slight 
flexion  and  adduction  of  the  smaller  toes;  this  flexion  of 
the  great  toe  can  be  produced  when  the  outer  border  of  the 
sole  only  is  stimulated,  and  consequently  it  can  not  be  at- 
tributed to  direct  mechanical  irritation  or  stretching  of 
the  small  flexor  muscles  of  the  sole.  The  movement  differs 
from  the  normal  flexor  response  in  that  it  is  slower  and 
smaller  in  range,  and  in  that  it  is  chiefly  a  flexion  at  the 
matatarso-phalangeal  joint.  Occasionally  the  only  effect 
is  contraction  of  the  inner  hamstrings,  but  as  a  rule  this  is 
associated  with  slight  flexion  of  the  toes. 

In  less  severe  injuries  stimulation  of  the  sole  still  evokes 
flexion  of  the  great  toe  with  contraction  of  the  hamstrings, 
while,  if  the  lesion  is  still  less  serious,  a  withdrawal  reflex 
of  the  whole  limb,  in  which  the  hamstrings,  tensor  fasciae, 
flexors  of  the  hip,  and  the  dorsiflexors  of  th'e  ankle  are  con- 
cerned, may  be  obtained,  but  still  with  flexion  of  the  great 
toe.  In  many  cases,  however,  an  extensor  response  can  be 
elicited  from  the  sole,  but  clinical  experience  and  post- 
mortem examinations  tend  to  show  that  during  the  first 
week  or  10  days  at  least  Babinski's  sign  occurs  only  with 
transverse  lesions,  which  are  not  complete.  We  have  re- 
peatedly seen  a  flexor  movement  of  the  toes  give  place  to 
an  extensor  between  the  seventh  and  the  tAventieth  day  after 
the  injury,  and  in  certain  cases  this  has  been  a  precursor  to 
1.37fJ4— 17 17 


258  WAR    SUEGEEY    OF    THE    NEEVOUS    SYSTEM. 

improvement.  Even  in  one  case  in  which  a  nnihiteral 
lesion  of  the  fifth  cervical  segment  produced  a  flaccid  pa- 
ralysis of  the  limbs  of  the  same  side  tlie  plantar  reflex  was 
absent,  or  only  a  slight  slow  flexion  of  the  great  toe  could 
be  obtained  during  the  first  two  weeks,  after  which  it  gave 
way  to  a  pure  extensor  response. 

SPINAL  SHOCK. 

Tliis  state  of  the  reflexes,  more  especially  the  abolition  of 
the  tendon  jerks  and  the  absence  of  the  Babinski's  sign,  in 
severe  but  not  necessarily  complete  anatomical  lesions  raises 
many  points  of  interest.  Even  if  we  accept  Dr.  Bastian's 
doctrine,  we  must  be  surprised  to  find  the  tendon  jerks  ab- 
sent, for  a  time  at  least,  in  such  a  large  proportion  of  incom- 
plete injuries.  This  clifi'ers  from  what  we  find  in  ordinary 
civil  experience,  except  in  cases  of  fracture  dislocation  of 
the  vertebral  column,  and  in  this  condition  the  medullary 
injury  resembles  that  produced  by  gunshot  wounds  of  the 
spine.  The  nature  of  the  lesion  can  not,  however,  explain  it, 
and  as  the  reflexes  disappear  even  v.dien  the  highest  spinal 
segments  are  injured,  their  absence  can  not  be  attributed  to 
the  distant  disturbances  that  have  been  described  in  the  first 
lecture.  The  most  obvious  common  factor  is  the  sudden  sev- 
erance of  a  portion  of  the  cord  from  the  influence  of  more 
orally  situated  centers  b}^  an  abrupt  section  or  by  a  physio- 
logical block.  This  produces  the  condition  which  is  gener- 
ally  known  as  ''  spinal  shock."  It  is  recognized  in  the  ex- 
perimental laboratory,  as  high  transsection  even  in  the  frog 
leaves  all  four  limbs  flaccid  and  inactive  to  stimuli  for  half 
an  hour  or  so,  and  the  higher  the  animal  stands  in  the  scale 
the  more  pronounced  and  persistent  are  the  symptoms  of 
shock.  In  man,  in  whom  the  spinal  mechanism  is  most  sub- 
ordinated to  the  higher  centers,  the  effects  of  shock  are  natu- 
rally most  proFiOunced.  and  the  caudal  portion  of  the  cord  is 
least  capable  of  acting  alone  as  an  effective  central  organ. 
Our  observations,  therefore,  only  extend  and  confirm  the 
experiences  of  physiologists,  and  show  that  the  sudden  isola- 
tion of  a  portion  of  the  cord  from  the  rest  of  the  central 
nervous  system  leaves  it  incapable,  for  a  time  at  least,  of 
subserving  even  the  simplest  reflex. 

The  unilateral  absence  or  depression  of  the  tendon  jerks 
in  cases  of  unilateral  lesion  is  interesting,  as  it  shows  that 
their  abolition  is  not  due  to  a  state  of  general  shock  or  to 
a  sudden  gross  traumatic  injury  of  the  cord,  but  that  it  must 
be  attributed  to  an  interruption  of  impulses  that  descend 
through  the  homolateral  half  of  the  cord,  which  produces  a 
functional  depression  on  this  side  only. 

We  have  not  yet  had  the  opportunity  of  determining 
whether,  in  cases  in  which  the  structural  lesion  is  not  com- 
plete, the  absent  reflexes  eventually  return,  at  what  date  they 
reappear,  and  with  what  other  symptoms  of  recovery  their 
reappearance  is  associated.  We  have,  however,  seen  the  knee 
and  ankle  jerks  absent  during  the  first  and  second  week  in 


FOREIGN   WAR  LITERATURE.  259 

cases  which  have  recovered  sufficiently  to  stand  and  absent 
for  longer  periods  iri  patients  who  later  regained  some  power 
of  movement  >vhile  under  observation. 

The  inability  to  elicit  reflex  moA'ements  from  the  sole  in 
caseK  of  complete  transverse  lesions  must  be  also  attributed 
to  the  functional  depression,  either  temporary  or  perma- 
nent, of  the  isolated  segments  of  the  cord.  It  has  been 
pointed  out  that  in  less  severe  cases  only  flexion  of  the  toes 
or  this  associated  with  contraction  of  the  hamstrings  is  ob- 
tained, and  that  only  in  less  severe  or  longer  standing  in- 
juries can  the  complete  flexion  reflex  be  evoked.  This  we 
might  expect,  for  when  the  activities  of  the  isolated  portion 
of  the  cord  are  depressed  by  shock  the  relatively  complex 
mechanisms  of  commissural  and  intersegmental  association 
naturally  suffer  more  than  the  simpler  and  more  rudimen- 
tary unisegmental  functions.  And  as  the  sole,  from  which 
the  reflex  is  most  easily  evoked,  lies  within  the  sensory  dis- 
tribution of  the  first  sacral  root,  and  the  flexors  of  the  toes 
and  the  hamstrings  are  innervated  chiefly  by  the  ventral  root 
of  the  same  segment,  the  contraction  of  these  muscles  on 
stimulation  of  the  sole  can  be  regarded  as  a  unisegmental 
reflex ;  additional  segments  would  be  concerned  in  flexion  of 
the  hip  and  knee  and  the  contraction  of  the  tensor  fasciae 
femoris  and  adductors,  which  are  included  in  the  full  flexion 
reflex.  Further,  in  these  cases  the  receptive  field  of  the  reflex 
is  much  narrowed,  and  is,  in  fact,  almost  invariably  limited 
to  the  sole,  where  the  threshold  of  eifective  stimulation  is 
normall}^  lowest. 

It  might  be  expected  that  the  effects  of  shock  on  the  lumbo- 
sacral enlargement  would  be  more  pronounced  the  lower  the 
lesion  lay  m  the  cord,  but  we  find  little  to  support  this  view ; 
the  loAver  limbs  have  been  as  flaccid  and  toneless  in  cases  of 
high  cervical  injury  as  when  the  lower  dorsal  segments  w^ere 
damaged,  and  when  the  lesions  have  been  probably  of  equal 
severity  there  has  been  no  evidence  of  less  shock  or  of  earlier 
recovery  when  it  lay  high  rather  than  low  m  the  cord.  This 
would  support  the  conclusion  drawn  from  the  observation  of 
unilateral  lesions  that  shock  is  not  a  direct  mechanical  dis- 
turbance of  functional  activity,  but  that  its  effects  depend 
on  the  interruption  of  the  neurotic  impulses  that  normally 
flow  continuously  from  the  higher  to  the  lower  levels  of  the 
central  nervous  system. 

Sherrington  has  pointed  out  that  the  effects  of  spinal  shock 
are  seen  in  experimental  animals  only  in  the  aboral  direc- 
tion, and  it  is  obvious  that  in  man  they  are  limited  to  seg- 
ments distal  to  the  lesion,  as  in  even  the  rudest  transverse 
lesion  no  symptoms  are  found  above  its  level  which  are 
attributable  to  shock. 

"  AUTOMATIC  "  MOVEMENTS. 

But,  though  the  shock  effect  of  these  severe  spinal  trau- 
mata almost  invariably  abolishes  or  depresses  seriously  the 
functions  of  the  isolated  segments,  in  a  group  of  four  cases 


260  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

in  which  the  lowest  dorsal  or  highest  lumbar  segments  were 
involved,  "  automatic  "  movements,  such  as  are  observed  in 
certain  spinal  animals,  occurred,  and  their  occurrence  can  be 
interpreted  only  as  the  result  of  a  reflex  overactivity  of  the 
isolated  segments.  In  one  of  these  cases  the  lesion  involved 
the  first  and  the  upper  part  of  the  second  lumbar  segment ;  in 
another  it  extended  from  the  lower  part  of  the  twelfth  dorsal 
to  the  middle  of  the  second  lumbar  segment;  in  a  third  it 
reached  as  high  as  the  eleventh  dorsal  segment  and  probably 
extended  some  distance  downward,  while  in  the  fourth  it  was 
probably  limited  to  the  third  lumbar  segment.  In  these  cases 
the  lesions  were  severe  or  total,  and  as  the  involuntary  move- 
ments were  identical  or  very  similar  in  all  four,  their  nature 
can  be  best  conveyed  by  describing  one  case  in  detail. 

These  alternate  flexion  and  extension  movements  of  the 
lower  limbs  obviously  represent  the  rudiments  of  the  lower 
physiological  mechanism  of  gait,  and  are  very  similar  to 
the  "  mark  time "  or  progressive  movements  seen  in  the 
"  spinal "  dog ;  their  nature  must  be  the  same  as  these 
reflex  movements  which  Sherrington  has  described  in  the 
spinal  animal. 

It  is  interesting,  however,  that  we  have  seen  such  in- 
voluntary reflex  movements  only  when  the  lesion  involved 
the  upper  lumbar  segments  of  the  cord,  and  that  they 
occurred  in  a  considerable  proportion  of  all  serious  in- 
juries at  this  level.  In  the  only  two  cases  in  which  the 
spinal  cord  has  been  examined  there  was  exceptionally 
little  distant  disturbance,  and  the  lower  lumbar  and  the 
sacral  segments  were  in  both  almost  intact.  It  is  also 
surprising  that  they  should  occur  at  least  as  early  as  the 
second  day.  Further  observations  will  be  necessary  to 
determine  the  significance  of  the  absence  of  direct  struc- 
tural damage  in  the  ventral  columns  in  the  two  cases  which 
came  to  autopsy. 

We  have  not  observed  any  "  automatic "  movements  of 
the  limbs  when  the  higher  cervical  segments  were  injured: 
in  fact,  these  are  always  then  flaccid  and  toneless,  and 
their  muscles  usually  wasted  early.  We  have,  however, 
obtained  a  reflex — which,  as  far  as  we  know,  has  not  been 
yet  described — in  cases  in  which  the  lesion  lay  in  or  above 
the  fifth  cervical  segment,  and  produced  paralysis  of  the 
upper  limbs.  Pricking,  pinching,  or  firm  stroking  on  the 
inner  side  of  the  arm  then  evoked,  generally  after  a  short 
latent  period,  a  sudden  and  strong  inward  rotation  and 
adduction  of  the  arm  on  the  same  side,  the  inward  rota- 
tion being  apparently  the  prime  and  chief  movement.  We 
obtained  this  reflex  in  most  of  the  cases  of  severe  cervical 
lesions  in  which  we  examined  for  it,  provided  there  was  not 
an  atrophic  palsy  of  the  arm. 

CERVICAL    SOFTENING. 

Injuries  in  different  portions  of  the  cord  naturally  pro- 
duce clinical  symi)toms  differing  not  only  in  the  extent,  but 


FOREIGN   WAR   LITERATURE.  261 

also  in  nature  of  the  jiaralysis.  One  of  the  most  striking 
types  is  that  which  results  from  an  incomplete  lesion 
of  the  cervical  enlargement.  Since  hemorrhages  and  sec- 
ondary changes  undoubtedly  occur  as  a  result  of  concus- 
sion more  readily  in  this  than  in  any  other  region  of 
the  cord,  and  since  they  are  more  liable  to  damage  the 
gray  than  the  white  matter,  the  arms  are  frecjuently  seri- 
ously paralyzed,  though  there  is  fair  or  unaffected  powder 
of  movement  in  the  lower  limbs.  Not  infrequently  the 
paralysis,  especially  that  of  the  arms,  develops  some  time 
after  the  infliction  of  the  wound,  but,  on  the  other  hand, 
it  is  not  uncommon  to  meet  joatients  with  gunshot  wounds 
of  the  neck  in  whom  all  four  limbs  were  at  first  paralyzed, 
who  had  regained  power  within  a  week  or  so,  the  arms  re- 
covering almost  invariably  later  than  the  legs. 

Lesions  of  certain  regions  of  the  cord  also  produce  special 
local  symptoms.  We  have,  for  instance,  repeatedly  seen 
unilateral  paralysis  of  the  diaphragm,  and  in  two  cases  at 
least  bilateral  palsy,  due  to  lesions  at  the  level  of  the  fourth 
or  fifth  cervical  segment ;  unilateral  palsy  of  the  dia- 
phragm also  occurred  in  two  cases  in  which  the  main 
lesion  was  to  the  second  cervical  segment,  but  it  was  not 
observed  in  any  patient  in  whom  it  lay  lower  than  the 
fifth.  The  occurrence  of  nystagmus  has  also  been  de- 
scribed as  a  result  of  lesions  in  the  higher  cervical  region, 
but  we  have  observed  it  in  only  3  of  the  63  cases  in  which 
the  cervical  segments  were  injured,  in  lesions  of  the  second, 
fifth,  and  seventh  segments.  It  was  slight  and  ill-sus- 
tained in  all  three,  and  disappeared  rapidly,  save  in  one 
patient,  in  whom  it  persisted  at  least  fifteen  days;  but  as 
in  this  case  the  exit  wound  was  in  the  neighborhood  of  the 
tip  of  the  mastoid  labyrinthine  concussion  can  not  be  here 
excluded. 

PALSY  OP  THE  CERVICAL  SYMPATHETIC. 

Disturbances  of  the  functions  of  the  cervical  sympathetic 
occurred  with  lesions  of  all  segments  between  the  second 
cervical  and  the  second  dorsal  included;  they  are  referred 
to  in  our  notes  on  36  cases,  and  in  thei  great  majority,  at 
least,  of  theses  injury  of  the  sympathetic  fibers  in  the  neck 
could  be  excluded.  The  most  common  and  prominent 
sympton  was  miosis,  or,  in  unilateral  lesions,  inequality 
of  the  pupils,  the  smaller  being  on  the  side  of  the  lesion, 
and  this,  as  a  rule,  failed  to  dilate,  or  dilated  less  rapidly 
and  less  completely  on  shading  the  eyes.  A  narrowing  of 
the  palpebral  fissures  in  one  or  both  eyes  and  some 
enophthalmos  was  also  pronounced  in  most  of  the  cases. 
Ptosis  was  also  frequently  observed,  especially  with  lesions 
of  the  lower  cervical  and  the  first  dorsal  segments. 

Disturbances  in  sweating  on  the  affected  side  were  also 
present  in  most  of  the  cases;  as  a  rule,  the  skin  of  the 
face,  neck,  and  shoulders,  as  well  as  the  hair  of  the  head 
on  the  side  of  the  spinal  injury,  was  merely  drier  and  less 


262  WAR   SUKGEEY   OF    THE    NERVOUS    SYSTEM. 

greasy  than  on  the  opposite  side;  but  during  the  warm 
weather  of  the  late  summer,  or  in  any  condition  that 
induced  sweating,  there  was  a  very  obvious  difference,  for 
the  skin  of  the  face,  neck,  and  shoulder  to  the  level  of  the 
second  rib  remained  dry  on  the  one  side,  while  it  was 
moist  and  covered  with  beads  of  sweat  on  the  other.  In 
certain  unilateral  lesions,  too,  a  diminution  of  tear  secre- 
tion was  observed  on  the  affected  side,  the  eye  being 
obviously  drier  and  presenting  a  more  staring  and  glassy 
appearance  than  the  normal;  a  few  patients  even  com- 
plained of  this  eye  being  "  stuck  "  or  difficult  to  open  in  the 
morning,  owing  to  the  lids  being  adherent  as  a  result  of 
the  drying  of  the  undiluted  conjunctival  secretion. 

Definite  vasomotor  disturbances  associated  with  paraly- 
sis of  the  cervical  sympathetic  were  less  common,  but 
in  several  cases  the  face  was  more  flushed  and  highly 
colored  on  the  affected  side,  especially  after  shaving. 

It  is  known  that  the  cilio-spinal  center  lies  in  the  lowest 
cervical  and  first  dorsal  segments,  while  the  spinal  center 
of  the  other  components  of  the  cervical  sympathetic  is 
found  in  the  two  upper  dorsal  segments,  and  that  these 
are  influenced  or  controlled  by  efferent  bulbar  fibers  which 
descend  uncrossed  through  the  cervical  cord.  It  must  be 
to  disturbance  of  the  latter  that  the  symptoms  just  de- 
scribed are  due  when  the  lesion  lies  above  the  eighth 
cervical  segment,  while  the  spinal  centers  themselves  are 
injured  when  the  lesion  lies  below  this.  It  is  an  interest- 
ing question  if  the  symptoms  due  to  lesions  in  those  two 
sites  differ.  We  have  not,  however,  observed  any  essential 
or  obvious  difference,  though  both  the  ocular  and  secretory 
disturbances  seemed  to  be  on  the  whole  more  prominent 
and  permanent  when  the  spinal  sympathetic  centers  were 
damaged  than  when  the  bulbar  efferent  fibers  were  in- 
volved; in  fact,  in  the  latter  case  the  symptoms  usually 
subsided  quickly,  and  often  disappeared  under  observation. 
Symptoms  of  irritation  of  the  cervical  sympathetic  did  not 
occur  in  any  casie  in  which  the  spinal  cord  only  was  injured. 

PIYPOTIIERMIA. 

One  of  the  most  interesting  types  we  have  observed  was 
due  to  injury  of  the  lower  part  of  the  cervical  enlargement, 
and  was  characterized  by  subnormal  temperature,  slow  pulse, 
low  blood  pressure,  and  scanty  secretion  of  urine.  All  the  10 
patients  in  whom  these  symptoms  occurred  died  within  eight 
days  after  the  infliction  of  the  wound,  and  in  all  the  lesion 
lay  in  approximately  the  same  region. 

On  admission  to  a  base  hospital,  generally  one  or  two  days 
after  the  injury,  the  most  striking  feature  was  the  cold,  col- 
lapsed condition  of  the  patient.  The  skin  was  generally  dry 
and  remarkably  cold  even  to  touch,  and  it  was  noted  in  some 
that  the  superficial  temperature  on  exposed  parts,  as  the  face 
or  hands,  was  apparently  no  lower  than  that  of  covered 
parts.     When  the  temperature  was  very  low,  a  touch  re- 


FOREIGN    WAR    LITERATURE.  263 

minded  one  forcibly  of  the  coldness  of  death— this  was  espe- 
cially so  in  a  man  seen  at  a  casualty  clearing  station  soon 
after  he  received  the  wound.     The  skin  was  also  generally 
cyanosed,  and  the  face  of  a  curious  slate  color.    The  tempera- 
ture varied  in  different  cases,  and  as  unfortunately  a  special 
thermometer  to  register  it  was  not  always  available,  in  4  of 
the  10  cases  we  can  only  say  that  it  was  lower  than  could  be 
registered  in  a  clinical  thermometer — that  is,  36°  C.=95°  F. 
In  one  of  the  other  six  it  sank  to  78.8°  F.   (26°  C.)  in  the 
rectum,  and  did  not  rise  above  80°  F.  during  the  24  hours  he 
lived  under  observation,  but  in  most  of  those  in  which  ac- 
curate observations  were  made  the  lowest  recorded  lay  be- 
tween 80°  and  84°  F.     In  a  few  it  rose  suddenly  before 
death  to  above  the  normal,  and  in  one  case  which  has  been 
already  recorded  by  Lieuts.  Oliver  and  Winfield  actually 
ros'3  from  80°  to  105.6°  F.— that  is,  25°  F.— in  26  hours;  in 
others  it  remained  low  till  the  patient  ceased  to  live.    In  one 
case  the  patient  lived  at  least  three  days  with  a  tem])erature 
not  rising  above  90°  F.,  and  in  two  it 'did  not  exceed  85°  F. 
foi-  24  hours,  but  as  these  cases  usually  did  not  come  under 
ou.r  observation  till  the  third  day,  it'  is  probable  that  life 
could  be  maintained  even  longer  with  this  low  temperature. 
The  temperature  was  always  taken  in  both  the  mouth  and 
axilla,  and  in  a  few  instances  in  the  rectum,  too;  the  ther- 
mometer in  the  mouth  generally  registered  slightly  higher 
than  in  the  axilla,  but,  except  in  one  case  in  which  it  was  a 
few  degrees  higher,  the  rectal  temperature  was  approxi- 
mately equal  to  that  in  the  mouth. 

In  all  cases,  too,  the  pulse  rate  was  very  slow,  while  the 
temperature  remained  low,  and  it  increased  in  frequency 
as  this  rose ;  in  one  case  it  was  only  22  per  minute,  and  in  the 
others  ranged  between  30  and  50  per  minute  till  the  tempera- 
ture approached  normal  limits.  In  one  patient  it  was  32  when 
the  temperature  in  the  mouth  was  80.6°  F.,  and  rose  to  102 
when  this  reached  98.8°  F.  The  pulse  was  also  very  soft 
and  of  low  tension  while  the  temperature  remained  down; 
■unfortunately,  sphygmomanometric  observations  were  pos- 
sible in  only  three  cases,  and  in  these  the  pressure  registered 
56,  72,  and  73  mm.  of  mercury. 

As  the  intercostal  muscles  were  paralyzed  in  every  case, 
respiration  was  wholly  diaphragmatic,  but  its  rate  was  ap- 
proximately normal,  except  in  one  in  which  it  was  only 
9  per  minute,  while  the  temperature  remained  under  80°  F. 
It  must  be,  however,  remembered  that  when  the  respiratory 
movements  are  much  restricted  their  rate  is  usually  in- 
creased, and  consequently  we  may  assume  a  relative  slowing 
of  respiration. 

The  fourth  special  symptom  was  the  small  amount  of  urine 
passed.  In  one  man  who  lived  48  hours  no  urine  was  se- 
creted; another  secreted  only  20  ounces  in  3  days;  a  third 
probably  only  8  ounces  in  4  days;  while  from  a  fourth, 
whose  temperature  varied  between  87°  F.  and  105°  F.  and 
his  pulse  rate  between  40  and  104,  only  20  to  25  ounces  could 
be  drawn  off  during  the  first  3  days,  but  the  daily  amount 


264  WAR   SUEGERY   OF    THE    NERVOUS  SYSTEM. 

increased  to  50  to  60  ounces  for  the  last  2  days,  when  his 
temperature  ranged  between  100°  F,  and  105°  F.  The 
amount  of  urea  was  estimated  in  two  cases  in  which  very 
little  urine  was  secreted,  and  its  percentage  was  approxi- 
mately normal. 

The  mental  state  of  these  patients  was  another  interesting 
feature;  when  the  temperature  was  very  low,  or  at  least 
below  85°  F.,  they  were  stuporose  or  extremely  lethargic, 
but,  with  the  exception  of  one  case,  they  could  be  roused, 
and  then  appeared  quite  intelligent  and  answered  questions 
rationally,  though  they  alwa^^s  tended  to  drift  quickly  again 
into  a  lethargic  and  apathetic  state,  unconcerned  with  their 
condition  and  immediate  wants.  As  their  temperature  rose 
this  mental  lethargy  quickly  passed  off,  and  they  became 
bright  and  fully  conscious  of  their  serious  condition — in 
fact,  their  mental  state  varied  directly  with  their  tem- 
perature. 

The  general  appearance  of  these  patients  with  low  tem- 
perature, slow  pulse  rate,  stupor  or  mental  lethargy, 
and  low  metabolic  exchange,  as  indicated  by  the  small 
amount  of  urine  of  normal  constitution  secreted,  reminded 
one  strongly  of  an  animal  in  hibernation,  and  as  in  the 
hibernating  animal  the  pulse  rate  and  amount  of  urine 
secreted  increased  and  the  stupor  passed  off  as  the  tempera- 
ture rose  to  normal  limits. 

Post-mortem  examinations  were  obtained  in  nine  of  the 
ten  cases;  in  two  the  chief  injury  was  to  the  sixth  cervical 
segment,  in  two  to  the  seventh,  in  one  the  seventh  and 
eighth  cervical  segments  were  damaged,  and  in  the  remain- 
ing four  the  eighth  cervical  and  the  first  dorsal.  In  four 
of  these  cords  there  Avere  practically  complete  transverse 
lesions;  in  the  others  the  injury  seemed  to  be  only  partial, 
but  except  in  one  of  these  a  microscopical  examination  has 
not  yet  been  made.  Further,  from  the  clinical  signs  a  com- 
plete transverse  lesion  would  not  be  diagnosed  in  at  least 
three  of  these  cases — in  fact,  one  was  able  to  move  both  legs 
from  the  time  he  came  under  observation  till  his  death. 
In  his  cord  microscopical  examination  revealed  hemor- 
rhages with  cedema  and  foci  of  necrosis  in  the  seventh  and 
the  upper  part  of  the  eighth  cervical  segments,  small  hem- 
orrhages and  swollen  axis  cylinders  above  the  lesion  as 
high  as  the  fourth,  and  a  cylindrical  cavity  descending 
through  the  dorsal  columns  from  the  first  to  the  third  dor- 
sal segment. 

A  condition  similar  to  that  above  described  has  been  re- 
peatedly produced  in  animals  by  section  of  the  cervical 
cord;  this  is,  in  fact,  followed  by  a  fall  in  temperature  and 
blood  pressure,  a  slowing  of  the  pulse  and  of  respiration, 
diminished  secretion  of  urine,  and  death  within  a  few  days. 
And  the  same  symptoms  have  been  observed  in  man  when 
the  cervical  cord  has  been  injured  by  a  fracture  or  disloca- 
tion of  the  neck.  Parkin,  for  instance,  records  a  case  of 
destruction  of  the  fifth  to  the  seventh  cervical  segments, 


FOREIGN   WAR    LITERATURE.  265 

in  which  the  temperature  fell  as  low  as  78°  F.  and  the 
pulse  rate  to  26-37  per  minute;  and  Nieden  another  case  of 
dislocation  of  the  first  dorsal  vertebra,  in  which  the  tem- 
perature gradually  fell  to  80.(5°  F.  l)efore  death  on  the 
eleventh  day,  and  the  pulse  rate  sank  to  30  per  minute.  The 
blood  pressure  was  evidently  very  low  in  both  these  cases, 
as  the  pulse  was  described  as  hardly  perceptible. 

On  the  other  hand,  we  have  seen  several  cases  of  com- 
plete or  very  severe  injury  between  the  fifth  cervical  and 
the  first  dorsal  segment  in  which  these  symptoms  were  not 
present. 

We  have  some  evidence  that  these  patients  do  react  to 
some  extent  as  cold-blooded  animals,  and  that  their  tem- 
perature may  vary  with  the  external  temperature;  in  one 
patient,  for  instance,  the  temperature  rose  from  84.2°  to 
95°  F.  when  he  was  placed  on  a  hot-water  bed  and  packed 
around  with  hot-water  bottles,  and  another  from  86°  to 
105.6°  F.,  when  he  was  brought  into  a  room  heated  to  70° 
F.  and  also  surrounded  by  warm  bedclothes  and  hot-water 
bottles.  This  interpretation  of  the  latter  observation  is  not, 
lioweA'er,  beyond  doubt,  as  a  final  rise  of  temperature  oc- 
curred in  other  patients. 

In  another  case  an  injection  of  pituitrin  brought  the  tem- 
perature for  a  few  hours  almost  up  to  normal,  and  in- 
creased the  pulse  and  respiratory  rates,  while  at  the  same 
time  the  patient,  who  had  been  very  dull  and  lethargic, 
became  temporarily  bright  and  intelligent. 

The  interpretation  of  these  observations  can  not  be  at- 
tempted here;  they  might  be  taken  as  evidence  of  the  exist- 
ence of  a  heat  regulating  center  in  the  lower  part  of  the 
cervical  enlargement,  as  Dr.  Hale  White  has  assumed,  or, 
on  the  other  hand,  the  fall  of  temperature  might  be  at- 
tributed to  diminished  heat  production  consequent  on  mus- 
cular inactivity;  a  similar  fall  occurs  in  curarized  animals. 
Probably  the  most  important  factors  are  deficient  thermo- 
genesis  and  a  visceral  vasomotor  palsy  produced  by  shock 
in  the  sympathetic  system.  Capt.  Shorten,  however,  in  a 
short  comment  on  the  case  published  by  Lieut.  Oliver  and 
Winfield,  suggested  that  the  sj^mptoms  may  be  due  to  the 
interruption  of  descending  fibers  in  the  cord  which  control 
and  regulate  the  activity  of  the  adrenals,  and  Prof.  Harvey 
Gushing,  who  kindly  saw  one  of  our  cases,  had  suggested 
previously  to  us  that  a  cervical  sjmipathetic  palsy  may  dis- 
turb the  functions  of  the  pituitary  and  that  this  may  inter- 
fere with  the  correlated  activity  of  the  suprarenals.  If 
Capt.  Shorten's  hypothesis  is  correct  we  could  expect  to 
find  hypothermia  and  its  associated  symptoms  more  com- 
monly in  cervical  and  bulbar  lesions,  and  its  absence  after 
section  of  the  cervical  sympathetics  argues  against  Dr.  Har- 
vey Cushing's  suggestion.  The  adrenals  appeared  normal 
to  the  naked  eye  in  one  of  our  cases. 


266  WAR   SURGERY    OF    THE    NERVOUS    SYSTEM. 

CERVICAL   PYREXIA. 

Benjamin  Brodie,  Chossat,  and  others  have  described  a 
rise  of  temperature  in  animals  after  injury  of  the  cervical 
cord,  and  Sir  Jonathan  Hutchinson,  Sir  Hermann  Weber, 
and  numerous  other  clinical  observers  have  observed  py- 
rexia with  similar  injuries  in  man.  As  in  most  of  our  pa- 
tients there  were  septic  wounds  associated  with  the  spinal 
lesion,  and  as  in  several  cystitis  coexisted,  particular  care 
is  necessary  in  interpreting  our  observations  on  this  point, 
but  some  are  unequivocal.  In  one  patient,  for  instance, 
with  symptoms  of  a  partial  lesion  in  the  fourth  cervical 
segment  and  a  small  clean  entry  wound  of  a  rifle  bullet 
just  below  the  tip  of  the  right  mastoid,  in  which  there  were 
no  signs  of  infection,  the  temperature  on  several  occasions 
rose  to  104°  F.  and  quickly  fell  again  to  normal.  In  this 
and  in  other  patients  the  pyrexia  was  not  associated  with 
any  signs  of  illness  or  discomfort,  and  the  pulse  rate  did 
not  vary  as  the  temperature  rose.  In  several  other  pa- 
tients w^ith  partial  or  unilateral  lesions  between  the  third 
and  sixth  cervical  segments,  whom  we  were  able  to  keep 
under  observation  for  several  weeks,  the  temperature  was 
frequentl}^  above  normal,  and  often  reached  102°  F.  to 
103°  F.  without  any  apparent  cause. 

Another  interesting  observation  was  persistent  shivering 
of  the  shoulders,  neck,  and  face  without  any  rise  of  tempera- 
ture of  disturbance  of  the  pulse  rate,  and  without  any  sub- 
jective feeling  of  coldness  associated  with  lesions  of  the 
lowest  cervical  and  upper  three  dorsal  segments.  This  oc- 
curred only  in  severe  injuries  of  this  region,  and  persisted 
over  several  days. 

POLYURIA. 

We  have  described  diminished  secretion  of  urine  with 
lesions  of  the  lower  part  of  the  cervical  enlargement,  but 
the  daily  quantity  is  frequently  much  increased  when  the 
injury  lies  in  the  middle  of  the  dorsal  cord,  especially  be- 
tween the  fifth  and  eighth  dorsal  segments.  From  one 
patient  with  a  total  transverse  lesion  between  the  seventh 
and  eighth  dorsal  segments  an  average  of  145  ounces  was 
drawn  off  by  catheter  during  the  first  six  days  he  was 
under  observation,  even  215  ounces  in  one  day.  During  the 
next  six  days  and  till  death  the  average  daily  amount  se- 
creted was  90  ounces.  In  another  patient  with  a  severe 
lesion  of  the  fifth  dorsal  segment  the  average  amount 
drawn  off  during  the  first  18  days  was  80  ounces;  and  in 
a  third,  who  had  sustained  a  complete  destruction  of  the 
eighth  dorsal  segment,  the  daily  average  during  the  first 
three  wrecks  was  125  ounces,  but  fell  during  the  next  three 
weeks  to  a  daily  average  of  66  ounces.  In  fact,  in  the  ma- 
jority of  patients  with  injuries  to  this  region  of  the  cord  in 
whom  observations  were  made,  an  excessive  amount  of 
urine  was  secreted.     Unfortunately,  we  have  not  yet  ob- 


FOREIGN   WAR   LITERATURE.  207 

tained  a  complete  anal3'sis  of  the  urine  when  it  is  in  great 
excess. 

This  polyuria  is  probably  due  to  paralysis  of  the  sym- 
pathetic fibers,  and  especially  of  the  vasoconstrictors,  to  the 
kidney.  Claude  Bernard  and  Sir  John  Rose  Bradford,  it 
will  be  remembered,  produced  it  by  section  of  the  splanch- 
nics  and  of  the  lower  dorsal  roots. 

PULSE    RATE. 

While  a  slow  pulse  rate  has  been  one  of  the  character- 
istic symptoms  of  severe  lesions  of  the  lower  part  of  the 
cervical  enlargement,  a  marked  and  persistent  acceleration 
of  its  rate  was  often  present  in  partial  lesions  of  this  region, 
especially  when  the  upper  two  dorsal  segments  w-ere  in- 
volved. In  one  case  of  partial  destruction  of  the  second 
dorsal  segment,  for  instance,  it  rarely  fell  below  100  per 
minute  and  was  frequently  120,  and  this  independently  of 
any  rise  of  temperature  or  other  obvious  cause.  In  another 
severe  injury  of  the  same  segment  it  ranged  between  72  and 
140  per  minute,  and  in  a  third  it  never  fell  below  120  per 
minute.  But  the  most  striking  alterations  are  perhaps  seen 
with  partial  injuries  of  the  four  lower  cervical  segments 
in  which  the  patient  seems  in  perfect  health  apart  from  his 
spinal  injur}^  In  one  such  patient,  who  remained  three 
months  under  observation  with  an  originally  slight  injury 
of  the  fourth  cervical  segment  which  later  progressed,  the 
pulse  rate  constantly  lay  between  100  and  120,  and  only 
occasionally  in  the  latter  part  of  this  period  fell  to  90  per 
minute,  and  in  a  similar  uncomplicated  case  of  injury  to  the 
fifth  cervical  segment  the  rate  varied  between  96  and  130  per 
minute.  It  was  always  regular,  however,  in  these  cases  and 
of  good  volume  and  fair  tension. 

VOMITING. 

When  the  mid-dorsal  region  is  severely  injured  the  ab- 
domen is  frequently  tense  and  blown  out  and  the  patient 
presents  the  symptoms  of  paralytic  distension  of  the  in- 
testines. But  a  more  striking  symptom  which  is  some- 
times associated  Avith  it,  but  which  often  occurs  without  any 
objective  symptoms  of  abdominal  disturbance,  is  vomiting. 
In  the  larger  proportion  of  the  cases  in  which  it  was  ob- 
served the  lesion  lay  in  the  sixth,  seventh,  or  eighth  dorsal 
segment. 

It  is  often  so  persistent  that  it  threatened  life,  as  in 
severe  cases  no  nourishment  could  be  kept  down.  In  several 
instances  it  set  in  within  a  few  hours  of  infliction  of  the 
wound,  and  in  many  severe  cases  persisted  till  death  or  as 
long  as  we  had  the  patients  under  observation.  It  Avas 
generally  forcible  and  projectile,  and  was  apparently  asso- 
ciated with  much  discomfort,  but  with  little  nausea,  though 
a  few^  patients  complained  of  the  feeling  of  sickness.  In 
mild  cases  it  occurred  only  some  time  after  taking  food. 


268  WAR   SUEGEKY   OF    THE    NEEVOUS   SYSTEM. 

and  this  alone  might  be  brought  up  in  a  half-digested  state, 
but  when  severer  it  was  more  or  less  constant  and  mucous 
stuff  occasionall}^  colored  with  bile,  and  in  a  few  instances 
bloodstained,  was  ejected.  In  some  of  our  notes  the  simi- 
larit}^  to  the  vomiting  of  a  tabetic  crisis  is  remarked  on. 

As  in  the  large  majority  of  cases  in  which  this  type  of 
vomiting  occurred  the  lesion  lay  in  the  region  of  the  sympa- 
thetic outflow  to  the  stomach  it  might  be  attributed  to 
irritation  or  disturbance  of  the  function  of  these  fibers. 
And  there  is  much  evidence  that  this  is  its  cause.  Almost 
without  exception  these  patients  complained  of  girdle  pains 
around  the  body,  or  on  one  or  other  side,  between  the  level 
of  the  xiphoid  and  umbilicus,  and  of  great  tenderness  to 
light  contact,  rubbing,  and  other  stimuli  in  the  region  in 
which  the  referred  pain  and  tenderness  associated  with 
gastric  disease  occurs.  Further,  in  seA^eral  there  was  a 
persistent  local  contraction  of  a  portion  of  the  abdominal 
muscles  between  the  xiphoid  and  the  umbilicus  correspond- 
ing to  the  cutaneous  hyperfesthesia,  which  increasecl  and 
produced  pain  Mdien  this  area  of  skin  was  stimulated.  In 
fact,  the  firm  resistance  and  tenderness  of  this  area  to  touch 
occasionally  gave  rise  to  the  suspicion  of  a  large  intra- 
abdominal lesion.  In  a  few  patients  the  intercostals  iner- 
vated  by  the  same  dorsal  roots  were  also  in  contraction, 
and  everted  the  ribs  to  which  these  were  attached. 

Vomiting  occasionally  occurred  after  injury  to  other  re- 
gions of  the  cord,  too,  but  in  most  of  these  cases  it  was 
associated  wnth  and  probably  due  to  intestinal  paralysis,  to 
severe  septic  infection,  or  to  the  cystitis  or  pyelonephritis 
which  occur  so  frequently  with  spinal  lesions.  In  a  few 
cases  of  cervical  injury,  however,  it  was  a  prominent  symp- 
tom, and  could  not  be  attributed  to  any  of  these  causes. 

When  severe  and  frequent,  such  vomiting  naturally  ex- 
hausted the  patient  and  induced  emaciation.  Great  loss 
of  flesh  also  occurs,  as  might  be  expected,  in  severe  cases 
which  run  a  downward  course,  but  it  is  an  interesting  fact 
that  it  was  seen  also  in  patients  with  relatively  slight  in- 
juries of  the  cervical  enlargement  who  took  food  well  and 
even  had  excessive  appetites.  We  have  observed  several 
patients,  for  instance,  with  unilateral  lesions  of  this  region 
producing  the  Brown-Sequard  syndrome,  but  apparently 
not  affecting  their  general  health,  in  whom  there  was 
extreme  emaciation.  In  some  of  these  th^s  pulse  rate  was 
increased,  and  there  was  slight  pyrexia,  but  otherwise  the 
visceral  functions  seemed  unaffected. 

PRIAPISM, 

Numerous  other  symptoms  occurred  as  a  result  of  spinal 
lesions,  to  which  time  will  not  permit  reference  here.  Pri- 
apism has  been  frequently  described,  especially  with  lesions 
in  the  cervical  region,  but  we  have  observed  it  in  only  a 
small  proportion  of  our  cases,  and  it  seemed  to  occur  rela- 
tively as  frequently  wath  lesions  of  the  dorsal  as  of  the 


FOREIGN   WAR   LITERATURE,  269 

higher  segments.  It  Avas  usually  merely  a  soft  turgescence 
of  the  penis.  If,  as  is  assumed,  it  is  merely  due  to  vascular 
engorgement,  it  is  interesting  to  note  that  it  occurred  in 
two  of  our  patients  with  Ioav  temperature,  low  blood  pres- 
sure, and  a  slow  pulse  rate;  it  was  present  in  one  man 
when  the  blood  pressure  was  only  78  mm.  of  mercury. 

TROPHIC   DISTURBANCES. 

Various  trophic  disturbances  were  common  in  the  severer 
cases,  especially  bullae  and  blisters  in  those  parts  of  the 
paralized  regions  which  were  subjected  to  any  pressure. 
Irregular  patches  of  red  or  strawberry-colored  cliscolora- 
tion,  which  were  scarcely  modified  by  pressure  and  disap- 
peared slowly  leaving  a  slight  mottling  of  tlw  skin,  also 
occurred  frequently  in  the  same  parts.  Joint  changes  were 
riot  common  in  the  early  stages,  though  there  Avas  occasion- 
ally effusion  with  the  knees  or  ankles  when  the  legs  were 
completely  paralyzed,  and  in  a  few  patients  we  observed 
early  arthritic  affection  of  the  fingers  and  AArist  when  the 
cervical  cord  was  damaged. 

HERPES. 

Herpes  occurred  in  nine  cases,  either  immediately  above  or 
at  the  upper  margin  of  the  sensory  loss.  It  developed  be- 
tween the  third  and  fifteenth  day,  and  in  three  instances 
recurred  in  the  same  area.  It  usually  first  appeared  as  a 
zone  of  diffuse  erythema  with  small  papules  which  later 
became  vesicular  or  pustular,  generally  in  a  region  in  which 
there  was  either  pain  or  tenderness.  It  usnalh^  lasted  T  to 
14  days  and  disappeared,  'leaving  some  desquamation  and 
brownish  discoloration  of  the  skin.  Such  larger  vesicles  as 
are  seen  in  idiopathic  herpes  were  not  observed,  and  in  one 
case  there  were  only  papules  and  vesicles  without  any 
erythema  of  the  skin.  In  two  cases  in  Avhich  post-mortem 
examinations  were  obtained  the  corresponding  spinal  gan- 
glia were  found  bruised  by  displaced  fragments  of  the  verte- 
bral column,  and  the  clinical  symptoms  or  the  course  of  the 
missle  made  it  probable  that  a  ganglion  was  damaged  in  the 
other  cases,  too ;  its  pathology  is  consequently  allied  to  that 
described  for  idiopathic  herpes  by  Barensprung,  and  con- 
firmed by  Drs.  Head  and  Campbell. 

The  state  of  sensation  in  the  herpetic  zone  was  variable; 
in  some  cases  there  was  only  excessive  tenderness  to  contact, 
rubbing,  cold,  and  other  stimuli,  associated  with  sponta- 
neous pain;  in  other  there  were  the  symptoms  of  a  root 
lesion:  that  is,  a  band  of  insensitiveness  to  pin  prick  and  to 
moderate  degrees  of  temperature,  with  loss  or  diminution  of 
tactility  within  it.  In  those  cases  in  which  there  Avas  defi- 
nite sensory  loss  it  Avas  found  that  this  Avas  not  coterminous 
or  did  not  correspond  Avith  the  area  of  th'3  eruption.  Sher- 
rington has  shoAvn  that  the  dermatomeres  are  not  superim- 
posed in  the  myomeres,  and  it  is  obvious,  too,  that  the  pe- 


270  WAR    SURGEEY   OF    THE    NERVOUS    SYSTEM. 

ripheral  distribution  of  the  radicular  fibers,  which,  when 
injured,  are  concerned  in  the  production  of  herpes,  do  not 
coincide  accurately  with  either. 

III.  THE  SENSOEY  DISTURBANCES  IN  SPINAL  INJURIES. 

Nearly  60  years  ago  the  first  valuable  contribution  to  this 
subject  was  made  by  Brown-Sequard,  who  from  both  clinical 
and  experimental  observations  concluded  that  a  one-sided 
lesion  of  the  spinal  cord  produces  motor  paralysis,  with 
hyperesthesia  and  loss  of  muscle  sense  on  the  same  side, 
and  in  addition  anesthesia  of  all  other  forms  of  sensibility 
on  the  opposite  half  of  the  body. 

These  conclusions  have  been,  however,  violently  attacked 
by  both  physiologists  and  clinicians^  and  even  Brown-Se- 
quard himself  later  modified  his  views,  but  they  have  formed 
the  basis  of  all  subsequent  contributions,  and  it  has  been,  in 
fact,  only  within  recent  years  that  any  important  additions 
or  modifications  have  been  made  to  them. 

The  exact  intraspinal  course  of  the  various  forms  of  sen- 
sation soon  began  to  excite  interest.  Many  workers,  follow- 
ing Brown-Sequard  and  Schiff.  held  that  pain  and  tempera- 
ture at  least  pass  upward  through  the  gray  matter,  while 
tactile  impressions  and  those  that  underlie  the  sense  of 
position  ascend,  according  to  Schiff,  through  the  dorsal 
columns.  Bechterew's  and  Bikel's  experiments,  however, 
make  it  probable  that  impressions  of  pain  are  conducted 
after  decussation  through  the  white  matter  of  the  ventral 
part  of  the  lateral  columns.  But  it  is  obvious  that  neither 
the  grouping  nor  the  course  of  sensory  impulses  within  the 
cord  could  be  determined  by  experiments  on  animals,  and  it 
is  not  surprising  that  the  most  reliable  conclusions  we  have 
were  obtained  from  clinical  observations  on  suitable  cases 
of  injury  or  disease  in  man.  It  is  largely  to  Petren  that  we 
owe  the  'most  accurate  and  comprehensive  summary  of  clini- 
cal observations.  From  the  collation  of  a  large  number  of 
cases  he  has  concluded  that  impressions  of  pain  and  tempera- 
ture pass  through  the  opposite  lateral  column,  "  muscle 
sense "  through  the  homolateral  dorsal  column,  while  two 
paths  are  open  to  tactile  impressions — one  through  the  un- 
crossed exogenous  fibers  of  the  dorsal  column,  another  in  the 
opposite  lateral  column.  A  careful  and  elaborate  analysis 
by  Drs.  Head  and  Thompson  of  sensory  disturbances  pro- 
duced by  spinal  lesions  confirmed  these  conclusions  and 
showed  that  when  the  appreciation  of  cutaneous  pain  is  lost 
that  produced  by  pressure  is  also  disturbed,  that  light  touch 
and  heavy  touch  are  lost  simultaneously,  and  that  the  appre- 
ciation of  all  degrees  of  temperature  is  abolished  together. 
They  also  found  that  the  ability  to  recognize  the  simulta- 
neous contacts  of  two  compass  points  depends  on  impulses- 
conducted  through  the  homolateral  dorsal  column.  The  af- 
fection of  other  forms  of  sensation  by  spinal  lesions  has  been 
also  investigated.    The  French  school  particularly  has  been. 


FOREIGN   WAR  LITERATURE.  271 

interested  in  the  appreciation  of  the  vibrations  of  a  heavy 
tuning  fork,  and  Egger,  as  well  as  Seiffer  and  Rydel,  have 
shown  that  disturbance  of  this  is  generally  associated  with 
loss  of  the  sense  of  position,  and  that  it  consequently  depends 
on  the  integrity  of  the  dorsal  columns.  Finally,  working 
with  Dr.  Head,  I  found  that  in  unilateral  spinal  lesions  the 
appreciation  of  weight  and  the  recognition  of  size  and  shape 
are  frequently  lost  in  the  paralyzed  side,  and  from  this  ob- 
servation, correlated  Avith  other  facts,  we  concluded  that  the 
impulses  that  subserve  these  functions  also  ascend  uncrossed 
through  the  dorsal  column;  we  also  confirmed  earlier  obser- 
vations that  the  appreciation  of  vibration  passes  by  this 
path,  too. 

The  nature  of  our  material,  and  especially  the  fact  that  we 
have  been  able  to  investigate  most  of  our  cases  only  in  that 
early  stage  in  which  certain  symptoms  may  be  attributed  to 
shock  and  other  to  partial  lesions  and  incomplete  blocking 
of  the  passage  of  sensory  impidses,  makes  extreme  caution 
necessary  in  drawing  final  conclusions  on  the  mode  of  sen- 
sory conduction  within  the  cord,  but  the  disturbances  we 
observed  must  have  an  important  bearing  on  this  subject. 
We  have  been,  however,  able  to  keep  certain  cases  under 
observation  as  long  as  10  to  12  weeks  after  the  infliction  of 
the  wound. 

RE310TE  SENSORY   DISTURBANCES. 

Anaesthesia  to  pain  and  temperature  is  certainly  the  most 
common  and  prominent  disturbance  of  cutaneous  sensibility; 
in  incomplete  transverse  lesions,  for  instance,  it  is  frequently 
found  that  though  tactile  stimuli  can  be  appreciated,  prick- 
ing or  the  application  of  heat  or  cold,  even  of  extreme  de- 
grees and  over  a  large  area,  evoke  no  sensation  apart  from 
that  of  contact.  Both  are  always  lost  on  the  side  opposite 
to  the  lesion  when  this  is  unilateral  and  lies  above  the  first 
lumbar  segment,  and  more  diminished  on  this  side  when  the 
injury  is  bilateral,  but  more  severe  on  the  one  side.  This 
crossed  relation  does  not  occur  when  the  lesion  lies  below 
the  tAvelfth  dorsal  segment.  During  recovery  from  bilateral 
lesions,  too,  tactile  sensibility  usually  returns  before  that  to 
painful  or  thermal  stimuli.  As  a  rule  both  these  forms  of 
sensation  were  lost  together,  but  in  some  cases  only  thermal 
appreciation  was  disturbed. 

We  have  not  yet  observed  a  case  with  primary  isolated 
affection  of  either  heat  or  cold,  but  during  recovery  sensi- 
bility to  either  may  reappear  some  tinxe  before  stimulation 
AA^ith  the  other  evokes  any  sensation.  Some  dissociation  is, 
however,  common  at  the  upper  level  of  the  remote  sensory 
loss,  but  this  will  be  discussed  later  when  the  mode  of 
decussation  of  the  sensory  paths  will  be  considered.  Many 
cases  seen  confirm  the  conclusion  put  forward  by  Drs. 
Head  and  Thompson,  that  when  pain  can  not  be  excited  by 
cutaneous  stimidi  it  can  not  be  produced  by  excessive  pres- 
sure; we  have,  however,  seen  cases  in  Avhich  heavy  pressure 


272  WAR    SURGERY    OF    THE    NERVOUS   SYSTEM, 

gave  pain  the  parts  Avhich  were  completely  anagesic  to  pin 
pricks,  but  it  must  be  admitted  that  in  some  of  these  at 
least  sensibility  to  prick  returned  within  a  relatively  short 
period.  Their  further  conclusion  that  sensibility  to  all 
degrees  of  temperature  is  affected  simultaneously  may  be 
accepted  if  it  is  borne  in  mind  that  when  the  disease  is 
slight  the  appreciation  of  moderate  stimuli  only  may  be 
lost;  everything  is,  however,  in  favor  of  their  view  that 
thermal  stimuli  of  all  degrees  pass  by  the  same  intraspinal 
paths,  but  that,  as  the  study  of  syringomyelia  shows,  heat 
and  cold  are  conducted  by  separate  fibers. 

Remote  tactile  anesthesia  was  present  in  only  a  very  feAv 
of  our  cases  of  vmilateral  spinal  lesion,  and  then  it  generally 
corresponded  with  the  analgesia — ^that  is,  it  occurred  on  the 
side  opposite  to  the  injury.  Frequently,  however,  especially 
when  cotton  wool  was  used  as  a  stimulus  over  hair-clad 
parts,  there  was  a  marked  subjective  difference  in  the  sensa- 
tions evoked  on  the  two  sides,  as  contacts  on  the  analgesic 
area  "  tickled .  less  "  or  were  "smoother"  than  on  the  side 
of  the  lesion ;  this  might  be,  on  the  one  hand,  attributed  to 
the  homolateral  hyperesthesia  or  unnatural  sensitiveness  to 
various  stimuli  which  Brown-Sequard  originally  described, 
but  when  the  sensations  were  compared  with  those  similarly 
evoked  from  normal  parts  it  was  evident  that  the  tickling 
element  in  the  sensation  was  defective  on  the  contralateral 
side.  On  the  other  hand,  this  difference  was  not  due  to  a 
diminution  of  tactile  acuity,  as  this  could  not  be  demon- 
strated when  other  stimuli  were  employed;  in  a  few  cases 
in  which  Von  Frey's  hairs  were  used  no  definite  thresh- 
old difference  between  the  two  sides  was  found.  Further, 
on  stroking  the  sole,  or  on  applying  any  other  stimulus 
which  naturally  tickles,  less  reaction  was  evoked  on  the  side 
opposite  to  the  injury.  It  appears,  therefore,  that  of  the 
two  spinal  paths  open  to  tactile  impulses  only  the  crossed 
fibers  which  are  closely  associated  with  those  that  carry  pain 
are  concerned  in  the  conduction  of  the  affective  impressions 
produced  by  many  tactile  stimuli.  This  observation  is  par- 
ticularly interesting,  as  lesions  of  certain  portions  of  the 
optic  thalami  show  that  at  this  level  the  impulses  that  un- 
derlie tickling  are  closely  related  to  those  of  pain. 

But  though  crossed  tactile  anesthesia  was  the  rule  in  our 
cases,  in  a  few  there  was  greater  diminution  of  sensibility 
to  light  touch  on  the  side  of  the  lesion,  or  on  the  side  of  the 
greater  motor  paralysis ;  even  homolateral  anesthesia  with 
crossed  analgesia  occurred  in  one  case. 

Another  interesting  form  of  dissociation  of  sensation  was 
represented  by  a  case  of  incomplete  injury  due  to  fracture  of 
the  left  side  of  the  sixth  cervical  vertebra  by  a  rifle  bullet. 
There  was  complete  paralysis  of  the  left  leg  and  of  the  trunk 
muscles  on  this  side,  and  all  the  movements  of  the  opposite 
limb  were  weak ;  on  the  right  side  there  was  complete  loss  of 
sensibility  to  touch,  pain,  and  temperature,  while  on  the  less 
paralyzed  half  of  the  body  pricks  and  other  painful  stimuli 


FOREIGN    WAR   LITERATURE.  273 

were  appreciated  normally,  and  thermal  sensation  was  only 
slightly  diminished,  but  there  was  complete  anesthesia  to 
both  light  and  heavy  touches.  The  sense  of  position  and 
the  appreciation  of  vibration  were  completely  lost  on  both 
sides  below  the  level  of  the  second  rib. 

In  such  a  case  we  have  the  converse  of  the  general  rule 
that  tactile  sensibility  suffers  less  severely  than  sensation  to 
pain. 

One  interesting  question  that  arises  from  these  observa- 
tions is  the  mode  of  decussation  of  the  sensory  fibers  of  the 
second  order  which  convey  impressions  of  touch,  pain,  and 
temperature,  and  the  obliquity  Avith  which  they  cross  to  the 
opposite  side  of  the  cord.  In  cases  in  which  the  lesion  was 
unilateral  the  upper  limit  of  the  remote  anesthesia  to  these 
different  forms  of  sensation  varied,  and  as  a  rule  the  upper 
border  of  the  contralateral  loss  did  not  correspond  to  the 
segmental  level  of  the  injury.  If  such  observations  were 
sufficientlv  numerous  it  would  be  obviously  possible  to  de- 
termine the  number  of  segments  necessary  for  the  complete 
decussation  of  each  set  of  fibers  of  specific  sensory  function. 
To  obtain  unequivocal  results,  however,  it  would  be  neces- 
sary to  consider  only  cases  in  which  the  lesion  interrupted 
these  fibers  after  their  decussation  is  completed  and  in  which 
their  interruption  is  total ;  unfortunately  such  cases  are  rare. 

In  the  mid-dorsal  region  the  crossing  of  pain  and  thermal 
impulses  apparently  occurs  quickly,  and  is  probably  com- 
plete about  one  segment  above  the  entry  of  the  dorsal  roots 
that  carry  them  to  the  cord.  Thermal  impressions  probably 
cross  here  less  rapidly  than  those  of  pain,  and  as  touch,  if  it 
is  affected,  is  generally  lost  to  the  slightly  lower  level,  the 
fibers  of  the  second  order  that  convey  it  probably  require 
two  segments  for  decussation.  This  conclusion  is  accepted 
with  full  recognition  of  the  fact  that  the  peripheral  over- 
lap of  the  tactile  root  fibers  is  greater  than  that  of  those 
concerned  with  pain  and  temperature.  The  same  order 
holds  for  the  upper  dorsal  segments,  but  here  the  obliquity 
of  decussation  is  greater;  pain  and  temperature  impres- 
sions do  not  cross  for  at  least  two  segments  after  their  entry 
into  the  cord,  and  three  are  frequently  required. 

The  higher  we  go  in  the  cervical  enlargement  the  slower 
does  the  decussation  become.  At  the  fourth  cervical  seg- 
ment, for  instance,  the  decussation  of  the  pain  impulses  is 
not  complete  till  five  to  six  segments  after  their  entry 
through  the  dorsal  roots,  and  that  of  thermal  impressions  for 
four  to  five  segments.  In  the  cervical  enlargement  pain  seems 
to  cross  within  about  four  segments,  thermal  sensibility 
within  three  to  four,  and  touch  somewhat  more  obliquely 
than  pain;  as  the  upper  margin  of  the  anesthesia  to  heat 
is  generally  slightly  higher  than  that  to  cold  it  may  be  as- 
sumed that  the  afferent  impulses  that  subserve  the  latter 
decussate  more  slowly. 

When  the  lesion  is  not  complete,  and  especially  if  it  is 
unilateral,  the  upper  border  of  the  sensory  loss  frequently 
137G4— 17 18 


274  WAK   SURGEEY   OF    THE    NEEVOUS   SYSTEM. 

retreats  caudalwards.  In  one  case,  for  instance,  the  upper 
margin  of  the  complete  analgesia  altered  from  the  sixth 
cervical  to  the  ninth  dorsal  root  area  in  tAvo  months,  and 
in  another  case  of  partial  bilateral  lesion  it  retreated  from 
the  upper  margin  of  the  right  cervical  root  area  to  the  level 
of  the  umbilicus  within  four  weeks.  A  parallel  recovery  of 
thermal  sensibility  may  be  frequently  observed,  but  it  is 
usually  much  slower,  and  heat  and  cold  are  then  frequently 
dissociated,  the  latter  recovering,  as  a  rule,  earlier  than 
sensation  to  heat;  but  the  converse  may  occur.  On  the 
other  hand,  even  when  the  lesion  lies  high  in  the  cord,  and 
has  produced  total  or  partial  loss  of  sensation  to  the  corre- 
sponding level,  it  is  not  uncommon  to  find  the  area  of  the 
lower  spinal  roots,  and  especially  the  skin  in  the  region  of 
the  anus,  sensitive  to  one  or  other  mode  of  stimulation. 
Further,  during  recovery  it  is  sometimes  in  these  regions 
in  which  sensation  first  reappears.  In  a  case  of  injury  of 
the  fourth  cervical  segment,  for  instance,  which  produced 
thermal,  pain,  and  tactile  anesthesia  to  the  root  of  the  neck, 
prick  could  be  well  appreciated  on  all  of  the  sacral  and  on 
the  fifth  lumbar  root  areas  on  the  left  side.  And  in  another 
the  third,  fourth,  and  fifth  sacral  areas  escaped,  though 
there  was  otherwise  total  loss  of  sensation  to  the  level  of  the 
umbilicus.  There  is  generally  a  remarkable  dissociation  of 
sensation  in  this  caudal  area;  occasionally  only  pain  can 
be  appreciated,  but  it  is  frequently  sensitive  to  touch,  too, 
and  either  to  heat  or  cold,  or  to  both.  The  area  sensitive 
to  thermal  stimuli  is,  however,  generally  smaller  than  that 
in  which  pain  can  be  felt.  As  a  rule  the  caudal  anesthetic 
part  in  such  cases  corresponds  roughly  to  areas  of  root  dis- 
tribution to  the  skin. 

These  two  phenomena,  the  caudalwarcl  recovery  of  sensa- 
tion and  the  escape  or  early  reappearance  of  sensation  in  the 
caudal  areas,  throw  light  on  the  arrangement  of  the  sensory 
fibers  of  the  second  order  as  they  ascend  through  the  ventro- 
lateral columns.  They  indicate  a  lamellar  arrangement  in 
which  the  fibers  that  carry  any  specific  form  of  sensation 
from  successive  dorsal  roots  lie  in  series;  and  as  there  is 
a  general  law  that  the  longer  ascending  fibers  lie  nearer  the 
periphery  of  the  cord,  those  that  convey  impressions  from 
the  lower  spinal  roots  are  probably  placed  lateral  to  those 
that  have  later  reached  the  contralateral  side.  The  escape 
of  the  sacral  root  areas  would  therefore  indicate  a  lesion 
that  involves  -only  the  more  mesial  fibers  of  the  sensory 
path,  while  an  anesthesia  disproportionately  low  in  relation 
to  the  level  of  the  spinal  injury  would  suggest  a  local  de- 
struction of  its  more  lateral  fibers.  When  it  becomes  pos- 
sible to  correlate  the  exact  histological  changes  in  these  cases 
with  the  results  of  careful  clinical  examinations,  definite 
conclusions  on  the  exact  course  of  the  fibers  that  carry  vari- 
ous forms  of  sensation  from  different  regions  of  the  body 
will  be  possible. 

Microscopical  examination  has  shown  that  extensive  soft- 
enings and  even  secondary  changes  occur  frequently  in  the 


FOEEIGN   WAR   LITERATURE.  275 

center  of  the  cord,  especially  in  the  cervical  region,  and  we 
might  consequently  expect  to  find  sensory  disturbances  re- 
sulting from  the  interruption  of  the  fibers  that  decussate  at 
the  level  of  such  a  lesion ;  certain  of  the  sensory  changes  that 
occur  in  syringomyelia  are  due  to  this  cause.  The  most 
striking  example  of  this  condition  that  we  have  seen  was: 

SUBJECTIVE  SENSORY  SYMPTOMS. 

Subjective  sensory  symptoms  were  not  uncommon;  pain, 
for  instance,  is  very  commonly  present  in  the  parts  that 
correspond  to  the  segmental  level  of  the  spinal  injury,  but 
here  it  may  be  due  to  irritation  of  the  dorsal  roots,  or  may 
be  only  associated  with  the  hyperesthesia  which  frequently 
occurs  in  this  region.  Distant  pain— in  the  leg,  for  instance, 
when  the  spinal  wound  was  in  the  cervical  region — occurred, 
however,  in  a  certain  number  of  cases  and  can  be  attributed 
only  to  the  spinal  lesion.  It  Avas  frequently  only  transient 
or  disappeared  within  one  or  two  weeks,  i3ut  occasionally 
persisted  as  long  as  we  had  the  patients  under  observation, 
in  one  case  for  two  months.  It  was  generally  described  as 
a  burning  or  an  aching  pain,  sometimes  only  as  a  numb- 
ness or  tingling,  which  increased  when  the  part  was  touched 
or  handled.  In  one  patient  it  was  so  severe  that  it  pre- 
vented sleep,  and  needed  morphine.  It  was  generally  most 
severe  at  night,  and  in  some  instances  increased  when  the 
part  was  exposed  or  moved,  though  there  might  be  no 
demonstrable  hyperesthesia.  It  sometimes  spread  over  the 
whole  side  of  the  body  below  the  level  of  the  injury,  but  it 
was  frequently  limited  to  the  foot  or  leg.  It  occurred  only 
with  relatively  slight  or  unilateral  lesions,  and  in  the  latter 
cases  was  always  on  the  same  side  as  the  injury  and  on  that 
on  which  there  was  no  cutaneous  sensory  loss.  In  a  few  in- 
stances, however,  no  sensory  loss  could  be  discovered  in 
either  side,  or  if  any  existed,  it  was  only  a  slight  diminution 
of  sensibility  to  pain  and  temperature. 

The  condition  laiown  as  hyperesthesia  was  extremely 
common;  it  may  occur,  as  was  originally  described  by 
Brown-Sequard,  on  the  side  of  the  injury  when  there  is  a 
unilateral  lesion;  or  on  areas  which  had  been  anesthetic  as 
sensation  recovers,  or  even  more  commonly  as  a  band  on 
one  or  both  sides  of  the  trunk  or  down  the  limbs,  at  the  up- 
per margin  of  the  sensory  loss. 

A  homolateral  hyperesthesia  in  Brown-Sequard  cases  is 
by  no  means  constant,  though  we  observed  it  occasionally. 
It  extended  over  the  whole  half  of  the  body  almost  up  to  the 
segmental  level  of  the  injury.  Here  pin  prick,  heavy  pres- 
sure, and  especially  scraping  or  even  rubbing  hair-clad  parts 
with  a  wisp  of  cotton  wool  produced  severe  pain  and  much 
more  reaction  than  these  stimuli  on  normal  parts.  The 
application  of  cold,  too,  usually  evolved  pain,  and  heat  of 
45°  C.  and  upward  caused  a  severe  burning  sensation.  In 
one  case  pin  prick  not  only  gave  more  discomfort  than  nor- 
mal, but  this  persisted  abnormally  long.    This  distant  hyper- 


276  WAR   SURGEEY   OP    THE    NERVOUS   SYSTEM. 

esthesia  always  showed,  however,  a  tendency  to  diminish 
rapidly  and  disappeared  in  some  cases  while  they  were  under 
our  observation.  Its  pathogenesis  has  been  already  the 
subject  of  much  discussion  and  experiment.  The  hypothe- 
sis that  it  is  due  to  section  of  efferent  inhibitory  fibers 
seems  very  improbable,  while  the  fact  that  it  is  generally 
transient  or  disappears  rapidly  is  more  in  favor  of  the  view 
that  it  is  due  to  an  inflammatory  reaction,  or  rather  to 
oedema  and  other  such  changes,  at  the  site  of  the  lesion 
than  to  overloading  to  the  afferent  tracks  that  remain  open 
to  sensory  impulses. 

An  excellent  example  of  hyperesthesia  in  areas  in  which 
sensation  is  recovering  was  a  case  in  which,  owing  to  a 
transverse  wound  across  the  back  of  the  neck  which  frac- 
tured the  sixth  and  seventh  cervical  spines  as  well  as  the 
lamina  of  the  sixth  vertebra,  a  complete  parajDlegia  with 
analgesia  and  thermoanesthesia  to  the  level  of  the  eighth 
cervical  root  areas  set  in  at  once.  Within  a  fortnight,  how- 
ever, there  was  complete  pain  loss  only  below  the  umbilicLis, 
and  the  appreciation  of  thermal  stimuli  was  only  dimin- 
ished above  this  level.  In  the  area  in  which  sensation  had 
recovered  pricks  produced  an  extremely  unpleasant  burn- 
ing sensation,  and  high  and  low  degrees  of  temperature  gave 
much  more  discomfort  than  on  normal  parts.  He  later  came 
under  the  care  of  Dr.  Head,  who  found  the  same  condition 
more  than  two  months  after  the  infliction  of  the  wound. 

Finally  we  come  to  the  hyperesthesia  which  is  so  com- 
monly found  at  the  upper  level  of  the  sensory  loss  on  one 
or  both  sides,  with  either  complete  or  partial  lesions.  On 
the  trunk  it  is  generally  associated  with  a  girdle  sensation 
of  pain,  burning,  tingling,  or  constriction,  and  on  the  limbs 
with  pain  or  paresthesia  over  the  areas  of  one  or  more 
dorsal  roots.  It  may  persist  for  weeks,  but  usually  dimin- 
ishes. When  severe  the  lightest  contact  or  even  the  approach 
of  anyone  to  his  bedside  may  be  feared  by  the  patient,  and 
the  movement  of  his  bedclothes  or  the  removal  of  his  shirt 
or  bandages  may  excite  severe  pain.  Local-  muscular  con- 
tractions are  frequently  associated  with  it.  The  state  of  sen- 
sation in  the  hyperesthetic  ai-ea  has  been  carefully  worked  out 
in  several  cases ;  it  is  found  to  be  variable.  No  loss  to  light 
contact  was  eA^er  found,  and  when  they  were  used  no  raising 
of  the  threshold  was  discovered  to  Von  Frey's  hairs,  but  in 
three  cases  contact  with  No.  4  and  No.  5,  which  only  gave 
a  maximal  threshold  reading  on  normal  parts,  produced  a 
sharp  stinging  or  burning  "  like  a  red-hot  iron "  on  the 
hyperesthetic  zone.  Pain  was  most  readily  produced  by 
any  moving  stimulus,  as  a  wisp  of  cotton  wool  or  by  scrap- 
ing with  any  rough  or  sharp  object,  but,  on  the  other  hand, 
moderate  pressure  generally  gave  no  discomfort. 

The  state  of  sensibility  to  pain  and  temperature  varied; 
in  one  group  the  threshold  to  pain  was,  if  anything,  dimin- 
ished, while  that  to  temperature  was  vmaffected,  but  any 
degree  of  cold  and  heat  above  45°  C.  evoked  much  pain.  In 
the  other  class  sensibility  to  pain  and  temperature  was  lost 


FOREIGN   WAR   LITERATURE.  277 

or  diminished  over  pari  of  the  area  tliat  was  painful  to  riib- 
bing  or  scrapino-. 

The  origin  of  this  hyperesthesia  is  interesting;  it  is  most 
commonly  attributed  to  irritation  of  the  corresponding  dor- 
sal roots,  and  this  seems  to  be  frequently  the  actual  cause, 
but  there  are  many  facts  which  prevent  us  from  accepting 
this  explanation  in  every  case.  It  is  often,  for  instance, 
much  more  extensive  than  it  would  be  if  due  to  irritation  of 
even  two  pairs  of  roots  in  the  neighborhood  of  the  wound; 
in  one  case  of  injury  to  the  spine  of  the  axis  it  extended  over 
both  upper  limbs  and  to  the  level  of  the  nipples,  and  in 
another  patient  in  whom  the  fourth  cervical  vertebra  was 
damaged  it  spread  not  only  over  both  arms  but  to  the  base 
of  the  xiphoid.  But  an  even  stronger  argument  is  the  fact 
that  in  cases  of  the  Brown-Sequard  syndrome,  in  which  there 
there  were  both  hypepesthesia  of  the  homolateral  side  and  a 
local  area  of  pain  and  tenderness  at  the  level  of  the  lesion, 
no  essential  dijfference  may  be  found  between  them.  It  is 
therefore  probable  that  in  many  cases  at  least  the  cause  of 
the  pain  is  to  be  found  within  the  cord,  and  that  it  is  due  to 
edema,  circulatory  disturbances,  or  slight  diffuse  lesions,  as 
Brown-Sequard  originally  postulated  as  the  explanation  of 
the  local  contralateral  hyperesthesia  he  described.  Finally, 
in  several  cases  we  have  found  no  injury,  on  post-mortem 
examination,  to  the  roots  w^hich  corresponded  to  the  areas 
that  were  hyperesthetic. 

PROGNOSIS, 

The  prognosis  during  the  first  two  weeks  in  any  one  case 
is  extremely  difficult,  and  it  must  be  admitted  that  there  is 
no  one  sign  or  symptom  from  which  we  can  draw  reliable 
conclusions  on  the  severity  of  the  lesion,  or  from  which  we 
can  say,  when  there  is  complete  motor  and  sensory  paralysis, 
as  there  nearly  always  is  in  the  earliest  stages,  whether  the 
cord  is  completely  divided  or  not.  It  must  be  remembered 
that  though  neither  the  cells  nor  the  fibers  of  the  spinal 
cord  do  regenerate,  very  considerable  improvement  may  oc- 
cur, as  at  least  part  of  the  early  symptoms  are  due  to  edema, 
circulatory  disturbances,  and  to  incomplete  damage.  The 
structural  damage  is  consequently  not  always  parallel  to 
the  functional  loss.  We  have  seen  that  the  knee  jerks  are 
absent  for  a  time  with  lesions  of  all  degrees  of  severity,  and 
this  consequently  can  not  be  a  guide  in  prognosis.  The  most 
reliable  information  is  perhaps  given  by  the  state  of  tone 
in  the  muscles  of  the  lower  limbs;  after  three  or  four  days, 
the  legs  are  generally  very  flaccid  and  their  muscles  tone- 
less when  the  lesion  is  severe  and  irrecoverable,  and  gradu- 
ally become  more  so  and  waste.  The  preservation  of  tone  in 
the  muscles  is,  on  the  other  hand,  an  indication  that  some 
improvement  may  be  expected.  Valuable  information  can 
be  also  obtained  by  stimulation  of  the  soles,  as  the  amount  of 
reflex  movement  that  results  varies  more  or  less  inversely 
with  the  severity  of  the  injury.    When  this  is  complete,  no 


278  WAR   SUEGEEY   OF    THE    NERVOUS  SYSTEM. 

reflex  muscle  contraction  can  be,  as  a  rule,  elicited,  while  in 
all  stages  of  slighter  damage  a  brisk  withdrawal  reflex  can 
be  obtained. 

Probably  no  serviceable  recovery  can  be  expected  if  the 
plantar  responses  are  flexor. 

In  less  severe  cases,  in  which  all  forms  of  sensation  are  not 
abolished,  the  amount  of  disturbance  of  the  latter  is  an  indi- 
cation of  the  amount  of  the  cord  damaged ;  we  have  gener- 
ally seen  the  promise  of  useful  recovery  when  tactile  stimuli 
could  be  felt  in  the  lower  limbs  within  the  first  two  or  three 
days. 

When  the  cervical  region  is  injured  the  upper  limbs  are 
usually  more  paralyzed  than  the  lower,  and  remain  flaccid 
and  waste  while  these  show  signs  of  recovery;  histological 
examination  shows  that  this  atrophic  palsy  of  the  arms  is 
due  to  extensive  softening  of  and  hemorrhages  into  the 
ventral  horns,  and  as  the  motor  cells  contained  in  them  are 
readily  destroj^ed  the  chance  of  much  improvement  is  slight. 

If  recovery  sets  in  early,  steadily  progressive  improve- 
ment may  be,  however,  expected,  unless  complications  occur. 
We  know  of  a  few  patients,  however,  in  whom  the  symptoms 
increased  after  movement,  as  Case  IV,  who  lost  again  the 
power  of  movement  he  had  regained  in  his  right  leg  during 
his  transference  to  England;  and  in  one  other  case  we  ob- 
served syringomyelia  develop  some  time  after  the  infliction 
of  the  injury. 

TREATMENT. 

Owing  to  the  nature  of  the  lesions  the  treatment  of  these 
spinal  injuries  is  naturally  unpromising.  The  damage  to 
the  spinal  cord  is  done  when  the  wound  is  inflicted,  and  we 
are  unable  to  influence  it  by  treatment.  In  many  cases  sur- 
gical intervention  and  the  removal  of  missiles  or  displaced 
bone  which  compress  the  cord  have  given  a  hope  of  greater 
recovery,  and  should  be  attempted  if  the  symptom.s  or  an 
X-ray  examination  make  it  probable  that  the  cord  is  com- 
pressed, and  that  there  is  any  prospect  of  recovery.  But 
it  must  be  realized  that  in  such  cases  the  symptoms  are  cer- 
tainly more  dependent  on  intramedullary  changes  produced 
at  the  time  rather  than  on  compression. 

Dr.  A.  R.  Allen  showed  experimentally  some  years  ago 
that  the  symptoms  produced  by  severe  contusion  of  the  cord 
can  be  relieved  and  recovery  made  possible  by  incising  the 
dorsal  columns  at  the  level  of  the  injury,  thus  draining  away 
oedematous  fluid  and  intramedullary  hemorrhages,  and  allow- 
ing the  swollen  fibers  to  expand,  but  it  is  necessary  that  this 
operation  should  be  performed  within  a  few  hours  of  the 
infliction  of  the  injury.  This  is  rarely  possible  in  warfare, 
and  the  early  symptoms  are  so  equivocal  that  if  resorted  to 
more  harm  than  good  might  easily  be  done. 

A  large  proportion  of  cases  of  spinal  injury  die  soon  after 
the  infliction  of  the  wound  from  shock  or  associated  wounds 
of  the  chest  or  abdomen.  Among  those  that  survive  the 
greatest  danger  is  from  cj^stitis  and  pyelonephritis  and  the 


FOEEIGN    WAR    LITEKATUEE.  279 

development  of  extensive  bedsores.  A  large  part  of  the  re- 
sponsibility consequently  falls  on  the  nursing.  When  cystitis 
is  threatened  or  has  developed  we  have  seen  excellent  i-esults 
from  suprapubic  drainage.  Finally,  the  danger  of  moving 
the  patient  must  be  borne  in  mind ;  the  risk  is  obvious  if  the 
A'ertebral  column  is  fractured  and  if  detached  pieces  of  bone 
lie  within  the  canal  transit.  Further,  we  have  evidence  that 
secondary  changes  are  more  liable  to  develop  after  move- 
ment ;  absolute  rest  is  consequently  advisable  during  the  first 
few  weeks  if  the  symptoms  hold  out  any  prospect  of  useful 
recovery.  

James  Collier:  Gunshot  Wounds  and  Injuries  of  the  Spinal  Cord. 

Lancet.  Aiir.  1,  lOlC.  p.  111. 

THE  NATURE  OF  THE  LESIONS. 

The  lesions  that  Collier  met  wdth  were  caused  by  high- 
velocity  bullets,  shrapnel,  fragments  of  shell  casing,  and 
by  the  concussion  of  high  explosives  without  any  external 
wound.  A  classification  of  the  lesions,  though  arbitrary,  is 
useful  in  considering  the  mode  in  which  they  are  produced. 
Often  more  than  one  kind  of  lesion  is  present.  The  follow- 
ing is  a  rough  classification:  (1)  Direct  lesions.  Any  lesion 
resulting  from  the  passage  of  a  missile  across  the  spinal 
canal,  whether  it  touch  the  spinal  cord  or  not,  is  a  direct 
lesion.  (2)  Indirect  lesions :  {a)  Those  due  to  the  indriving 
of  bone,  etc.,  into  the  spinal  canal,  {h)  Impact  lesions  where 
the  missile  strikes  against  the  bony  wall  of  the  spinal  canal. 
{c)  Concussion  lesions  from  the  shock  of  high  explosions. 
(3)  Seconclar}^  lesions:  Perithecal  and  intrathecal  hemorr- 
hage, medullary  hemorrhage  and  thrombosis,  meningitis, 
edema.  These  lesions  are  important  as  the  cause  of  the  deep- 
ening of  symptoms,  often  at  a  considerable  time  after  the  in- 
jury. (4)  Remote  lesions  which  may  be  found  anywhere  in 
the  spinal  cord  and  chiefly  near  the  surface :  Spots  of  necro- 
sis, sievelike  rarefaction,  punctiform  hemorrhages,  edema, 
swelling  of  axons.  These  lesions  are  produced  by  the  sudden 
raising  of  the  intraspinal  pressure  caused  by  the  passage 
of  the  missiles  through  the  intraspinal  space  or  by  a  general 
concussion  effect.  They  are  w^ell  marked  in  cases  of  concus- 
sion without  external  wound. 

The  mode  of  production  of  the  direct  injury  is  clear.  The 
passage  of  a  fast-moving  projectile  through  a  tissue  causes 
not  only  a  heat  effect  generated  by  the  friction  but  an  intense 
raising  of  the  pressure  in  the  tissues  for  some  distance  round 
the  track,  and  if  the  bullet  cross  the  spinal  canal,  which  con- 
tains a  fluid  pressure,  this  momentary  and  severe  pressure 
effect  is  transmitted  to  the  whole  of  the  nervous  system 
confined  within  the  cerebrospinal  space.  The  cerebrospinal 
space  being  an  elastic  cavity  the  increase  of  pressure  caused 
by  the  ])assage  of  the  bullet  w^ill  be  greatest  at  the  site  of 
the  track  and  w^ill  decrease  in  proportion  to  the  distance 
from  the  track,  but  will  be  greater  below  the  site  of  passage 
than  above  it,  because  the  lower  portion  of  the  spinal 
canal  is  more  closed  and  therefore  less  elastic.     The  damage 


280  WAR   SUEGEEY   OF    THE    NERVOUS   SYSTEM. 

to  the  spinal  cord  even  when  the  bullet  does  not  touch  the 
cord  nor  lacerate  the  membranes  is  therefore  greatest  where 
the  bullet  has  crossed,  but  it  extends  for  a  considerable 
distance  above  and  below  this.  Lesions  of  the  cord  in  places 
remote  from  the  chief  seat  of  injury  are  not  infrequently 
found  which  are  attributable  to  this  increase  of  pressure, 
and  these  are  always  more  marked  in  the  distal  part  of  tlie 
spinal  cord.  The  intracranial  effect  of  this  increase  of 
pressure  is  the  immediate  loss  of  consciousness  which  is 
sometimes  met  with,  and  more  often  in  cervical  injuries  than 
in  those  lower  down.  Possibly  the  initial  loss  of  conscious- 
ness may  be  an  index  that  the  bullet  traversed  the  spinal 
canal.  This  certainly  holds  good  for  the  cervical  region, 
for  in  three  of  my  cases  of  cervical  injury  where  conscious- 
ness was  not  lost,  although  the  initial  symptoms  were  severe, 
complete  recovery  occurred.  It  seems  impossible  that  a 
bullet  can  cross  the  spinal  canal  without  causing  the  most 
severe  and  irreparable  of  transverse  lesions,  and  one  may 
argue  that  in  all  the  cases  where  relative  or  complete  recov- 
ery occurs  the  lesion  has  been  an  indirect  one — either  an  im- 
pact lesion  or  due  to  the  indriving  of  bone.  It  is  likely 
that  a  bullet  does  not  so  often  cross  the  spinal  canal,  but  is 
more  often  deflected  by  the  bony  wall. 

Mode  of  production  of  mvpact  lesion. — The  passage  of  a 
high-velocity  bullet  in  the  immediate  vicinity  of  the  spinal 
canal  or  the  impact  of  a  projectile  upon  the  bones  formujg 
the  spinal  canal  may  cause  lesions  of  the  spinal  cord  some- 
times very  severe  notwithstanding  that  the  walls  of  this 
canal  remain  intact.  How  are  these  local  concussion  lesions 
produced?  The  anatomical  relations  of  the  spinal  cord 
practically  forbid  any  such  displacement  of  the  cord  within 
the  canal  as  could  bring  it  in  contact  with  the  bony  wall  and 
so  bruise  either  directly  or  by  contrecoup.  Col.  Gordon 
Holmes  has  shown  that  these  impact  lesions  show  their 
greatest  intensity  immediately  under  the  point  of  impact 
and  closest  to  the  bullet  track,  as  the  case  may  be.  The  fol- 
lowing is  an  explanation  of  the  way  in  which  these  indirect 
local  lesions  of  the  cord  are  produced.  The  contents  of  the 
spinal  canal  which  intervene  between  its  parietes  and  the 
spinal  cord,  and  made  up  of  the  perithecal  fat  and  vessels, 
the  theca  and  the  cerebrospinal  fluid,  may  be  regarded  as 
fluid,  and  the  pressure  within  the  spinal  canal  as  a  fluid 
pressure,  contained  in  a  vessel  which  has  one  rigid  wall, 
the  spinal  canal,  and  one  elastic  wall,  the  compressible 
vessels  of  the  cord,  etc.  Any  lines  of  force  either  from  ex- 
cessive vibration,  from  impact,  or  from  compression  trans- 
mitted from  one  spot  in  the  rigid  wall  will  have  their  most 
intense  effect  upon  the  nearest  point  of  the  elastic  wall, 
i.  e.,  the  nearest  spot  in  the  spinal  cord  and  little  elsewhere, 
the  force  becoming  rapidly  spent  upon  the  elastic  wall  as  it 
radiates.  The  damage  to  the  spinal  cord  produced  in  this 
way  by  indirect  injury  may  be  from  the  most  severe,  with 
symptoms  of  a  total  transverse  lesion  with  no  recovery,  to 
the  slightest,  with  complete  recovery. 


POEEIGISr   WAR   LITEEATURE.  281 

Concussion  lesions. — Severe  indirect  injuries  of  the  spinal 
cord  may  occur  from  the  bursting  of  high-explosive  shells 
when  the  back  is  turned  toward  the  force  of  explosion  with- 
out any  external  w^ound  occurring,  without  any  detectable 
lesion  of  the  bones,  and  even  without  bruising  of  the  soft 
tissues. 

In  such  cases  as  these,  where  severe  spinal  lesions  have 
been  prockiced  by  the  force  of  high  explosion  at  a  distance 
without  any  external  woimd.  it  is  possible  to  conceive  that 
there  has  been  such  distortion  of  the  spinal  column  as  might 
produce  a  subluxation  of  the  vertebroe  v,hich  became  imme- 
diately reduced,  and  that  during  this  subluxation  the  bony 
rings  which  make  up  the  spinal  canal  crossed  to  such  an 
extent  as  to  produce  a  severe  local  transverse  lesion  of  the 
cord.  That  such  a  subluxation  is  possible  has  been  proved 
experimentally  upon  the  cadaver,  and  that  it  can  severely 
pinch  the  spinal  cord  has  also  been  proved,  and  there  is 
much  evidence  in  the  records  that  such  a  subluxation,  imme- 
diately reduced,  is  one  of  the  lesions  that  may  occur  in  cases 
of  broken  back.  Collier  examined  one  such  case  in  which  a 
total  transverse  lesion  resulted  from  a  fall  from  a  haystack. 
The  spinal  cord  was  almost  severed  within  the  membranes, 
and  although  he  macerated  the  bones  he  could  find  no  sign  of 
fracture.  He  did  not,  however,  see  that  there  was  any  evi- 
dence in  favor  of  the  occurrence  of  such  a  subluxation  in 
the  cases  under  consideration,  and  the  histories  of  the  above 
cases  and  of  several  others.  We  must  therefore  regard  these 
lesions  as  impact  lesions.  It  seems  remarkable  that  the  im- 
pact of  the  force  of  the  explosion  upon  the  dorsal  surface  of 
the  body  could  be  sufficient  to  produce  local  spinal  concussion 
and  a  sharply  local  lesion  of  the  cord  without  any  evidence 
of  severe  bruising  of  the  skin  and  soft  tissues.  In  his  three 
cases  and  in  several  others  that  he  had  heard  of,  the  lesion 
was  in  the  lower  dorsal  region.  It  is  a  point  of  great  interest 
as  to  whether  such  severe  local  lesions  from  explosion  occur 
in  other  regions. 

Root  lesions. — Sometimes  the  lesions  produced  by  projec- 
tiles affect  the  spinal  roots  after  they  have  left  the  thecal 
space  to  a  much  greater  extent  than  they  affect  the  spinal 
cord  and  thecal  contents.  This  seems  to  be  the  case  when 
there  has  been  much  fracture  and  crushing  of  the  bone, 
and  especially  in  the  region  of  the  transverse  processes. 
There  is  usually  much  swelling  and  edema  in  the  injured 
region  of  the  spine.  Such  root  lesions  are  not  entirely  due 
to  direct  injury,  for  they  may  be  widely  spread  when  the 
injury  is  comparatively  local.  They  may  result  from  sub- 
periosteal hemorrhages  and  periosteal  swelling,  which 
strangle  the  roots  in  the  intervertebral  foramina;  or  from 
pachymeningeal  hemorrhage. 

Intrathecal  hemorrhage. — Among  the  many  lesions  of  the 
spinal  cord  met  with  resulting  from  bullet  wounds  there 
are  two  which  merit  special  comment.  The  first  of  these 
lesions  is  intrathecal  hemorrhage.  Blood  effused  into  a  free 
thecal  space  finds  its  way  with  the  stream  of  cerebrospinal 


282  WAR    SUEGEEY    OF    THE    NERVOUS   SYSTEM. 

fluid  into  the  lower  part  of  the  thecal  space  aroimd  the  cauda 
equina  and  himbo-sacral  enlargement,  and  if  massive  in 
quantity  may  distend  that  space,  causing  pressure  upon  the 
roots  and  epiconus,  and  clotting  there  may  cause  such  mat- 
ting and  cicatrization  as  may  completely  destroy  by  pressure 
and  evascularisation  the  caudal  equina,  and  if  it  extend 
high  enough  the  lumbar  enlargement  as  well.  Smaller  effu- 
sions by  clotting  and  the  formation  of  condensing  adhesions 
may  cause  local  signs  of  nerve-root  involvement.  In  a  severe 
condition  of  this  kind  where  there  has  been  extensive  intra- 
thecal hemorrhage — due,  let  us  say,  to  a  lesion  of  the  mid- 
dorsal  region — the  physical  signs  in  the  lower  extremities 
m.ay  resemble  exactly  those  due  to  a  complete  lesion  of  the 
Cauda  equina  or  of  the  lumbo-sacral  enlargement.  In  the 
less  severe  condition  the  local  deposit  and  subsequent  cicatri- 
zation of  blood  clot  round  individual  roots  of  the  cauda 
may  cause  physical  signs  difficult  of  explanation  unless  the 
possibility  of  the  occurrence  of  intrathecal  hemorrhage  and 
its  results  are  kept  in  mind. 

It  is  easy  to  conceive  of  cases  of  thecal  hemorrhage  where 
the  matter  round  the  cauda  equina  is  less  severe  and  gives 
rise  to  partial  lesions  of  the  cauda  only,  and  therefore  in  cases 
where  the  bullet  lesion  of  the  spinal  cord  is  above  the  lum- 
bar enlargement  and  unusual  conditions  of  reflexes,  spasm, 
and  contracture  are  present  in  the  legs,  it  is  well  to  consider 
whether  a  condition  of  thecal  hemorrhage  and  matting  of 
the  cauda  equina  may  not  exist.  Local  wasting  of  muscles 
and  local  loss  of  faradic  excitability  may  be  indications  that 
such  a  condition  exists.  The  early  diagnosis  of  this  condi- 
tion in  such  a  stage  as  to  allow  of  the  removal  of  the  blood 
by  lumbar  puncture  and  washing  out  with  citrate  solution 
is  apparently  impossible,  for  the  initial  aspect  of  nearly  all 
the  spinal  lesions  resulting  from  bullets  is  that  of  total 
transverse  lesion,  and  therefore  the  development  and  deep- 
ening of  the  signs  of  involvement  of  the  cauda  equina  can 
not  be  detected. 

REFLEX  ACTION. 

-  It  is  usually  held  that  the  initial  condition  of  reflex  action 
after  the  occurrence  of  severe  lesion  of  the  spinal  cord  is 
that  there  is  complete  loss  of  both  jerks  and  superficial  re- 
flexes, or  that  if  the  loss  is  not  complete  the  only  sign  of 
reflex  action  left  is  a  feeble  flexor  response  occurring  in  the 
toes,  only  obtainable  from  plantar  stimulation,  and  that  the 
early  presence  of  the  extensor  response  or  its  early  return 
is  indicative  that  the  lesion  is  not  complete  and  is  of  good 
prognostic  import.  Col.  Gordon  Holmes  has  laid  it  down 
very  clearly  that  the  condition  of  the  plantar  reflexes  in  all 
the  cases  which  he  has  examined  shortly  after  the  injury  has 
been  either  that  they  are  completely  absent  or  that  there 
is  a  reduced  flexion  response,  but  he  is  careful  to  add  that 
his  examinations  have  taken  place  not  earlier  than  the  s:"c- 
ond  day  after  the  injury. 


FOREIGN   WAR   LITERATURE.  283 

There  may  be  four  consecutive  stages  in  the  condition  of 
the  plantar  reflexes  following  a  transverse  lesion  of  the 
cord:  (1)  An  initial  extensor  response;  (2)  either  a  com- 
plete absence  of  any  reflex,  which  may  be  the  result  of  shock 
or  of  isolation  alteration,  or  a  reduced  flexion  reflex  which 
is  the  result  of  isolation  alteration  which  may  come  on  rap- 
idly; (3)  the  extensor  response,  which,  when  persistent,  is 
indicative  of  a  less  severe  lesion  or  alternatively  of  more 
recovery  than  the  reduced  flexion  reflex;  (4)  the  normal 
flexion  reflex  which  returns  when  recovery  is  complete.  The 
condition  of  the  plantar  reflex  is  therefore  an  index  of  the 
severity  of  the  damage  to  the  spinal  cord  and  an  important 
early  indication  as  to  whether  recovery  is  occurring  or  not. 

Col.  Gordon  Holmes  has  made  the  very  interesting  sugges- 
tion that  the  simple  flexion  of  the  toes,  which  can  be  ob- 
tained only  by  stimulating  the  sole  in  cases  of  severe  trans- 
verse lesions  of  the  cord,  and  which  Collier  has  called  the 
"  reduced  flexor  response,"  is  a  unisegmental  reflex  involving 
the  first  sacral  segment  only,  and  that  when  the  physio- 
logical vitality  of  the  lumbar  enlargement  is  much  reduced 
by  isolation  from  the  higher  nervous  sj^stem  the  only  reflex 
response  that  can  be  obtained  is  a  unisegmental  reflex.  Col- 
lier's observations  incline  him  to  support  strongly  Col.  Gor- 
don Holmes's  theory.  He  has  repeatedly  noticed,  in  a  case 
where  some  recovery  is  occurring  and  where  the  reduced 
flexor  response  is  changing  to  the  extensor  response,  that  a 
minimal  stimulus  wdll  produce  flexion  of  the  toes  and  a  more 
severe  stimulus  will  result  in  extension  of  the  toes,  or  that 
there  is  first  flexion  and  subsequent  extension  of  the  toes, 
but  never  the  reverse.  That  is  to  say,  the  threshold  for  the 
unisegmental  reflex  is  lower,  as  one  would  expect. 

Another  most  important  point  that  the  experience  of  this 
war  has  brought  out  is  that  the  influence  of  the  higher  ner- 
vous system  upon  the  reflex  action  and  muscle  tone  of  the 
spinal  cord  is  strictly  homolateral  so  far  as  the  cord  is  con- 
cerned. That  is  to  say,  that  a  total  unilateral  lesion  of  the 
cord  produces  complete  flaccidity  w^ith  loss  of  knee  and 
ankle  jerk  and  reduction  of  superficial  reflex  upon  the  side 
of  the  lesion.  This  will  explain  those  cases  in  which  we 
meet  with  an  extensor  response  upon  one  side  and  a  reduced, 
flexor  response  upon  the  other,  in  that  one  has  a  transvfe^ge  ■*^" 
lesion  more  complete  upon  one  side  than  upon  the  other. 

Contracture  is  a  phenomenon  which  is  intimately  asso- 
ciated with  t\\&  condition  of  reflex  action.  In  these  para- 
plegic cases  wfth  which  we  are  dealing  there  are  three  con- 
ditions of  contracture  of  the  feet:  (1)  The  dropped  foot 
with  retracted  toes.  This  is  the  ordinary  pes  cavus  of 
silastic  states — the  crystallization  of  the  extensor  response. 
(2)  The  retracted  foot  with  retracted  toes.  The  calcaneus 
position  is  often  extreme.  The  ankle  jerk 'is  always  lost 
and  the  anterior  tibial  jerk  marked.  An  extensor  plantar 
reflex  is  ahvays  present.  (3)  The  dropped  foot  with 
dropped  toes,  the  position  being  similar  to  that  of  peripheral 


284  WAR   SUEGEEY    OF    THE    ISTEEVOUS    SYSTEM. 

neuritis.  The  plantar  reflex  is  either  absent  or  there  is  a 
reduced  flexor  response. 

Collier  has  observed  in  several  cases  the  dropped  foot 
with  dropped  toes  gradually  changing  into  the  spastic  pes 
cavus  with  a  change  of  the  plantar  reflex  from  the  reduced 
flexor  to  the  extensor  type  in  cases  where  some  improvement 
has  taken  place,  and  therefore  considered  that  the  dropped 
foot  with  dropped  toes  indicates  a  more  complete  transverse 
lesion  and  that  it  is  produced  by  a  relatively  greater  mus- 
cular tone  in  the  flexors  of  the  toes  than  elsewhere,  and 
that  it  is  associated  with  the  reduced  flexor  response  just 
as  the  pes  cavus  is  associated  with  the  extensor  response  in 
less  severe  transverse  lesions. 

The  calcaneus  position  with  retracted  toes  is  a  very  re- 
markable phenomenon.  It  has  been  persistent  in  those  cases 
in  which  I  have  met  with  it,  and  has  been  always  associated 
with  loss  of  knee  and  ankle  jerk  and  increase  of  anterior 
tibial  and  hamstring  jerks.  The  extensor  response  and  ac- 
tive withdrawal  reflex  have  always  been  present. 

Collier  carefully  examined  the  electrical  excitability  of 
the  calf  muscles  and  of  the  anterior  tibial  muscles  in  ex- 
treme cases  of  the  equinus  and  calcaneus  positions,  and 
found  that  there  is  no  difference  in  the  faradic  excitability 
of  these  muscle  groups,  thus  proving  that  these  positions 
of  feet  and  toes  are  not  due  to  any  secondary  lesions  of  the 
Cauda  equina  or  lumbo-sacral  enlargement. 

He  met  with  one  curious  reflex  phenomenon  in  the  leg 
in  a  way  comparable  to  the  curious  reflex  which  Col.  Gordon 
Holmes  has  observed  in  the  arm  in  a  case  of  cervical  lesion. 
His  case  was  one  of  a  mid-dorsal  lesion,  total  upon  the 
right  side  of  the  cord  and  severe  upon  the  left.  The  right 
leg  was  completely  flaccid  and  the  only  sign  of  reflex  action 
present  was  that  on  stimulating  the  sole,  after  a  latent  period 
of  four  seconds  or  more,  a  feeble  flexion  and  adduction  of  the 
thigh  occurred.  This  reflex  was  easily  tired  out,  and  was 
only  obtainable  on  gentle  stimulation  of  the  sole. 

The  physical  signs  obtaining  in  the  lower  limbs  in  trans- 
verse lesions  of  the  cord  seem  to  be  the  same  whatever  the 
level  of  the  lesion  above  the  lumbar  enlargement. 

There  is  one  question  which  he  put  to  each  of  the  speakers 
who  followed  him :  What  is  the  ultimate  condition  of  the 
paralyzed  region  in  cases  of  total  transverse  lesion  of  the 
cord  which  are  long  survived  ?  His  own  suggestion  was  that 
the  slow  process  of  physiological  deterioration  which  we  call 
"  isolation  dystrophy  "  may  reach  such  a  point  that  no  signs 
of  activity  of  the  lumbar  enlargement  remain. 

To  the  usual  types  of  paraplegia  resulting  from  lesions 
of  the  spinal  cord  and  representing  diiferent  degrees  of 
isolation  of  the  distal  segment,  namely,  "  paralysis  in  ex- 
tension "  and  "  paralysis  in  flexion  " — we  might  speak  of  a 
third  type — that  of  complete  flaccid  paralysis.  For  it  is 
from  this  stage  of  complete  flaccid  paralysis  that  the  other 
types  successively  develop  when  improvement  is  occurring,. 


FOREIGN   WAR   LITERATURE.  285 

and  to  this  t^^pe  they  successively  return  Avhen  there  is  an 
increasing  lesion  or  from  long-standing  isolation  of  the 
distal  segment.  There  is,  of  course,  no  sharp  separation 
between  these  types ;  they  merge  into  one  another  gradually. 

DISTINCTION  BETWEEN  ROOT  LESIONS  AND  CENTKAL  LESIONS. 

The  diagnosis  between  lesions  of  the  roots  and  lesions  of 
the  central  gray  matter  is  sometimes  impossible,  as,  for  ex- 
ample, when  a  lesion  of  either  of  these  structures  is  complete. 
It  is  sometimes  quite  simple  when  a  single  root  or  so  is 
damaged  and  there  is  characteristic  sensory  and  motor  loss 
in  the  area  of  distribution  of  the  damaged  root.  In  many 
cases,  however,  the  diagnosis  is  far  from  a  simple  matter, 
and  in  some  of  these  both  lesions  may  exist  together.  The 
following  points  may  be  useful  in  the  diagnosis:  (1)  In  the 
cervical  region  extensive  root  lesions  are  only  met  with 
when  there  is  severe  injury  of  the  bones,  especially  of  the 
transverse  processes  and  spines,  and  these  are  recognizable 
by  deformity,  swelling,  and  edema,  and  radiography  in  the 
absence  of  these  signs,  an  atrophic  palsy  of  the  arms  is 
probably  the  result  of  a  central  lesion,  if  it  is  extensive. 
(2)  In  central  lesions  the  upper  limit  of  the  sensory  loss  is  a 
line  more  or  less  transverse  to  the  axis  of  the  limb — that  is 
to  say,  the  sensory  loss  is  of  the  "  glove "  or  "  stocking " 
pattern,  in  contrast  to  the  more  or  less  longitudinal  limita- 
tion which  obtains  in  root  lesions.  (3)  In  the  cervical 
region  a  relative  escape  of  the  long  columns  or  early  signs 
of  recovery  in  these  with  severe  paralysis  of  the  upper  limbs 
is  in  favor  of  a  root  lesion,  and  may  suggest  the  correct 
diagnosis  at  an  early  stage.  (4)  In  the  lumbo-sacral  region 
the  most  certain  indication  is  the  IcA^el  of  the  wound  of  the 
spine  if  this  can  be  determined  with  certainty. 

DISTURBANCES    OF    SENSIBILITY. 

The  chief  points  of  interest  in  this  connection  are  the 
paths  taken  by  the  sensory  fibers  in  their  spinal  course,  the 
sensory  loss  resulting  from  unilateral  lesions,  and  the  ex- 
planation of  remote  pains.  The  usually  accepted  paths  of 
sensation  in  the  spinal  cord  are  as  follows:  (1)  The  path 
for  touch  is  a  double  one,  in  the  homolateral  dorsal  column 
and  in  the  crossed  lateral  column;  (2)  pain,  heat,  and  cold 
are  conveyed  by  separate  fibers  in  the  crossed  ventrolateral 
column;  (3)  sense  of  position,  of  passive  movement,  of  vi- 
bration and  recognition  of  form,  and  of  the  compass  points 
are  conveyed  in  the  homolateral  dorsal  column.  The  cross- 
ing of  the  sensory  fibers  in  the  cord  occupies  one  to  two 
segments  in  the  lower  dorsal  region,  but  increasingly  more 
segments  as  the  cord  is  ascended,  so  that  in  the  cervical 
region  some  five  segments  are  occupied  by  the  crossing. 
There  is  no  crossing  below  the  last  dorsal  segment.  The  path 
for  painful  and  thermal  stimuli  crosses  more  rapidly  than 


286  WAK   SURGEEY   OF    THE    NEKVOUS   SYSTEM. 

does  touch.  Consequently  a  unilateral  lesion  of  the  cord 
does  not  produce  a  Brown-Sequard  syndrome  when  the 
lesion  is  at  the  level  of  the  first  lumbar  segment  or  below 
this. 

The  symptoms  of  the  unilateral  lesion  are  that  there  is 
motor  paralysis,  loss  of  sense  of  position  and  of  passive 
movement,  and  of  appreciation  of  vibration,  form,  and  com- 
passes upon  the  same  side  below  the  lesion,  and  loss  of  pain, 
heat,  and  cold  upon  the  opposite  side.  The  bilateral  loss 
in  the  region  of  the  lesion  from  the  involvement  of  both 
right  and  left  crossing  fibers  is  narrower  for  pain  and  tem- 
perature than  for  touch.  This  bilateral  loss  is  much  nar- 
rower in  the  dorsal  than  in  the  cervical  regions,  on  account 
of  the  increasing  obliquity  of  the  crossing  fibers.  Collier's 
observations  have  been  in  accord  with  the  above  scheme  v/ith 
one  exception.  In  the  majority  of  his  cases  of  imilateral 
lesion  of  the  cord  the  vibration  sense  has  been  lost  or  most 
affected  upon  the  opposite  side,  and  this  has  obtained  both 
in  severe  and  in  slight  lesions.  He  must  admit  that  he  has 
no  pathological  evidence  in  such  a  case. 

Remote  pains  are  very  obstinate  in  some  cases.  Their 
mode  of  origin  is  obscure.  Obviously,  they  are  only  met 
with  in  those  cases  w^here  the  sensory  conducting  tracts  are 
relatively  intact.  The  usual  symptom-complex  that  he  has 
met  with  is  that  there  is  a  transverse  lesion  in  the  dorsal 
region,  with  good  recovery  of  sensibility  and  some  recovery 
of  power  in  the  legs.  There  is  considerable  rigidity  of  the 
legs,  and  phasic  flexor  spasms  are  invariably  present,  and 
there  is  more  sphincter  trouble  present  than  the  condition 
of  recovery  of  motion  and  sensation  would  lead  one  to  ex- 
pect. There  are  three  kinds  of  pain:  Dull  persistent  pain, 
sharp  lancinating  pains,  and  cramp.  They  are  said  always 
to  disappear  if  the  patient  recovers.  His  experience  is  that 
they  certainly  persist  if  he  does  not  recover. 

There  are  three  possible  explanations  of  these  pains: 
(1)  That  they  may  be  caused  by  irritation  of  the  sensory 
tracts  in  the  region  of  the  lesion;  (2)  that  they  may  be 
caused  by  meningeal  adhesions  and  matting  of  the  cauda 
equina  by  the  organization  of  intrathecal  extravasation  of 
blood;  (3)  that  they  may  be  the  result  of  the  muscular 
rigidity  and  flexor  spasms.  Col.  Gordon  Holmes  is  in  sup- 
port of  the  first  of  these  causes,  since  in  some  cases  the  pain 
is  distributed  from  the  lesion  downward  to  the  feet.  The 
similarity  of  these  pains  to  those  which  obtain  in  conditions 
of  chronic  spinal  meningitis  suggests  that  meningeal  ad- 
hesions and  irritation  of  the  roots  are  present  in  some  of 
the  cases.  The  fact  that  they  disappear  as  recovery  advances 
and  persist  if  there  is  no  further  recovery  points  to  the  con- 
dition of  local  muscular  spasm  as  being  the  chief  cause  in 
some  of  the  cases. 

KARE    SYMPTOMS. 

Among  the  rare  symptoms  which  have  been  described, 
hypothermia   and   anuria   in   cases   of   cervical   lesion   and 


FOEEIGN    WAR   LITERATURE.  287 

vomiting  in  mid-dorsal  lesions  have  not  come  under  my  ob- 
servation. These  are  early  symptoms  and  are  either  rapidly 
fatal  or  they  do  not  persist,  so  that  we  do  not  see  them  in 
the  later  stages.  Pyrexia  and  tachycardia  in  cervical  cases 
have  both  come  under  my  notice,  as  has  also  polyuria  in 
dorsal  cases.  Herpes  zoster  from  injury  to  the  root  ganglia 
is  necessarily  an  early  symptom  and  has  not  occurred  in  any 
of  Collier's  cases.  Neither  has  he  observed  anything  ap- 
proaching the  remarkable  rythmic  movements  which  have 
occurred  early  in  so  large  a  proportion  of  Col.  Holmes's 
cases  of  lesions  in  the  upper  lumbar  region. 

Cervical  shivering  has  been  met  with  in  lesions  of  the 
lower  cervical  and  the  upper  three  dorsal  segments  only, 
and  the  lesions  in  all  the  cases  have  been  severe. 

PROGNOSTIC    INDICATIONS. 

In  nearly  all  the  cases  the  initial  clinical  picture  is  that  of 
a  total  lesion  of  the  cord,  and  in  the  early  stages  for  prog- 
nostic indications  as  to  how  much  of  the  transverse  lesion  is 
anatomical  and  how  much  physiological  we  must  look  to 
the  condition  of  the  reflexes.  The  early  reappearance  of  the 
plantar  reflex  if  lost  at  first  and  the  change  from  the  flexor 
to  the  extensor  type  soon  after  the  seventh  day,  or  the  pres- 
ence of  an  extensor  response  earlier  than  this,  are  certain 
indications  that  the  lesion  is  partial  and  that  some  recovery 
will  occur.  Persistent  loss  of  the  plantar  reflex  and  long- 
lasting  flexor  response  are  indications  that  the  lesion  is  se- 
vere and  that  useful  recovery  is  highly  improbable.  Early 
return  of  the  knee  jerk  and  of  the  ankle  jerk  is  of  good 
prognostic  import.  Even  in  the  less  severe  cases  the  knee 
and  ankle  jerks  do  not  return  before  the  fourth  day,  and 
their  reappearance  before  this  date  gives  hope  that  com- 
plete recovery  may  occur.  Col.  Gordon  Holmes  is  of  opinion 
that  the  presence  of  an  extensor  response  is  a  certain  indi- 
cation that  the  lesion  is  incomplete.  These  remarks  apply 
to  each  leg  individually.  The  condition  of  the  reflexes  on 
one  side  has  no  bearing  as  to  the  recovery  of  the  opposite 
limb.  The  further  prognostic  indications  are  simple.  They 
depend  upon  the  date  of  return  and  the  rapidity  of  return  of 
sphincter  control,  of  sensibility,  and  of  motor  power.  Early 
return  of  sphincter  control  is  one  of  the  best  of  signs.  In  two 
cases  where  recovery  has  been  complete,  and  in  two  other 
cases  where  recovery  has  been  nearly  complete,  some  sphincter 
control  returned  within  a  week  of  the  injury. 


It  is  only  natural  to  suppose,  in  spite  of  the  clear  exposition  by 
Holmes,  that  a  legitimate  difference  of  opinion  should  exist  regard- 
ing the  institution  of  operative  treatment.  These  cases  are  hopeless 
in  such  a  large  proportion  of  instances  that  the  desire  to  aid  them 
by  operative  measures  is  a  most  human  impulse.     In  the  following 


288  WAR   SUEGERY   OP    THE    NERVOUS   SYSTEM. 

abstract  of  the  Congress  at  Koenigsberg,  Michaelis  adheres  to  con- 
servatism, whereas  Gnleke  finds  himself  forced  into  a  more  radical 
position.  Marburg  and  Eanzi  lend  unqualified  approval  to  the 
doctrine  of  conservatism.  Leva  emphasizes  the  important  point 
that  spinal  shock  may  early  simulate  complete  severance  of  the  cord. 

Michaelis:  Injuries  of  the  Spinal  Cord    ( VerletzAiugen  des  raicken- 
marks  Intcnialioiial  Abstract  of  Surgcrij,  Mar.  1916.) 

Michaelis,  at  a  meeting  of  the  Verein  filr  'wissenschaftUche 
Heilkunde^  of  Konigsberg,  reported  the  case  of  a  patient 
wounded  by  a  bullet  which  inflicted  a  small  wound  of  entry 
in  the  back  of  the  neck,  somewhat  to  the  left  of  the  middle 
line,  and  at  the  level  of  the  fourth  cervical  vertebra.  There 
was  no  wound  of  exit,  though  tlie  lower  jaw  on  the  left  side 
was  badly  shattered.  A  day  after  the  infliction  of  the 
wound  both  arms  and  legs  were  paralyzed,  but  there  was 
no  paralysis  of  the  bladder.  The  paralysis  of  the  right  arm 
and  leg  soon  began  to  disappear,  leaving  onl}^  a  slight  weak- 
ness of  the  right  arm.  A  skiagram  showed  slight  injury  to 
the  fourth  cervical  vertebra  at  the  junction  of  its  body  with 
its  arch.  Viewed  from  in  front,  the  bullet  could  be  seen 
lying  behind  the  much  shattered  horizontal  ramus  of  the 
left  lower  jaw.  No  active  treatment  was  attempted  during 
the  first  fortnight,  as  it  was  hoped  that  the  paralysis  of 
the  left  arm  and  leg  would  disappear  spontaneously.  Treat- 
ment of  the  fractured  vertebra  by  Glisscn''s  extension  appa- 
ratus was  impracticable,  owing  to  the  fracture  of  the  jaw. 
The  fragments  were  united  by  bronze  wires  and  the  bullet 
was  removed.  As  there  was  no  improvement  in  the  paral- 
ysis of  th«  left  side  after  a  month,  laminectomy  was  per- 
formed, on  the  assumption  that  the  paral5^sis  was  due  to 
pressure  on  the  cord  by  a  fragment  of  bone  or  to  peripachy- 
meningitis with  local  edema  of  the  cord.  The  arches  of 
the  third,  fourth,  and  fifth  cervical  vertebrae  were  removed, 
but  no  loose  fragment  of  bone  could  be  found.  There  were, 
however,  signs  of  peripachymeningitis.  To  the  left  of  the 
middle  line  the  dura  was  adherent  to  the  fourth  cervical 
vertebra  over  a  small  area.  This  adhesion  was  severed. 
After  the  dura  had  been  opened  and  a  considerable  quan- 
tity of  cerebrospinal  fluid  had  escaped,  a  narrow  groove 
was  seen  passing  across  the  cord  from  behind  and  to  the 
left,  forward  and  outward.  This  wound  of  the  cord,  which 
had  been  gouged  by  the  bullet,  was  closed  by  catgut  liga- 
tures passing  upward  and  downward  so  as  to  unite  the 
upper  and  loAver  margins  of  the  groove.  The  wound  in 
the  dura  was  then  closed  and  the  operation  completed. 
Three  days  later  the  movements  of  the  left  big  toe  were 
regained,  and  during  the  following  days  the  paralysis  of 
the  left  leg  gradually  receded  upward.  Eleven  days  after 
the  operation  there  were  active  movements  about  the  ankle, 
and  three  days  later  the  patient  could  also  move  his  legs 


FOREIGN   WAR   LITERATURE.  289 

slightly  about  the  knee.  Movements  of  the  left  arm  did  not 
begin  to  return  till  about  four  weeks  after  the  operation, 
when  first  the  thumb,  then  the  fingers,  and  finally  the  rest 
of  the  arm  began  to  regain  the  power  of  movement,  the 
paralysis  gradually  receding  upward.  Though  the  use  of 
the  left  leg  was  almost  completely  restored,  that  of  the 
arm  remained  much  impaired.  Michaelis,  while  insisting 
that  the  operation  was  very  successful,  admitied  that  the 
reason  for  this  success  was  not  perfectly  clear.  It  might 
have  been  due  to  relief  of  pressure  on  the  cord,  which,  in 
its  turn,  might  be  traced  to  the  drainage  of  cerebrospinal 
fluid.  The  improvement  might  also  have  been  largely  due  to 
the  closing  of  the  groove  in  the  cord. 

Leva  reports  that  he  has  often  seen  paralysis  of  the  blad- 
der and  intestine,  as  well  as  sensory  disturbances,  disappear 
spontaneously,  and  marked  improvement  in  other  symp- 
toms occur,  even  in  cases  in  which  there  was  evidence  of 
complete  transverse  section  of  the  cord  {vollsfdndige  Quer- 
schnittlaesion) .  It  was  therefore  unwise  early  in  the  case 
to  diagnose  total  division  of  the  cord  and  to  give  an  unfa- 
vorable prognosis.  Brown- Sequard's  unilateral  lesion  did 
not  run  such  a  favorable  course  as  the  total  transverse  lesion 
{Querlaesion) .  In  some  cases  of  injury  to  the  cord  there 
were  only  a  few  isolated  symptoms.  Thus,  in  one  case  in 
which  certain  nuclei  of  the  medulla  were  involved,  the  symp- 
toms were  paralysis  of  the  recurrent  nerve  and  unilateral 
atrophy  of  the  tongue.  In  anotlier  cape  the  symptoms  con- 
sisted of  difficulty  in  swallowing,  loss  of  the  patellar  reflexes, 
and  static-atactic  manifestations.  In  a  third  case  weakness 
of  the  legs,  diminution  of  the  tendon  reflexes,  and  difluse 
sensory  disturbances  were  observed. 

Guleke  said  tliat  he  had  come  to  tlie  conclusion  that  it  was 
often  extremely  difficult  to  learn  the  extefit  to  which  the 
cord  had  been  injured,  and  that  he  was  therefore  in  favor 
of  early  operation  as  a  rule,  for,  though  this  principle  led 
to  superfluous  operations,  it  also  saved  the  lives  of  many 
who  would  otherwise  liave  died.  He  had  performed  20  lam- 
inectomies, and  in  none  had  any  harm  been  done.  He  did 
not  advise  this  operation  in  cases  complicated  by  severe 
pneumonia,  meningitis,  open  and  much  infected  wounds,  or 
"  urosepsis."  Hemothorax,  on  the  other  hand,  is  no  contra- 
indication, but  when  it  is  present  the  operation  should  be 
performed  under  local  anesthesia.  In  10  of  his  cases  the 
cord  was  completely  crushed,  and  they  all  terminated 
fatally;  in  five  other  cases  death  was  due  to  sepsis.  There 
were,  therefore,  only  five  recoveries  among  his  20  cases;  but 
he  was  certain  that  three  of  the  patients  who  recovered 
would  have  died  had  not  the  operation  been  performed.  In 
these  three  cases  sjDlinters  of  bone  or  Indlets  were  found  in 
the  cord,  which  they  had  much  injured. 

1. 3764—17 19 


290  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

Marburg,  O.,  and  Ranzi,  E.:  Spinal-Cord  Injuries  Due  to  Bullets 

("Cber  Riickenmarkschusse).    Wein.  klin.  Wchnschr.,  1915,  xxviii, 
113. 

The  authors  report  a  series  of  35  spinal-cord  injuries 
treated  at  the  von  Eiselsberg  Clinic,  Vienna.  Although 
nothing  particularly  new  is  offered,  the  conclusions  drawn 
may  be  summarized  as  follows : 

1.  In  contradistinction  to  brain  injuries  it  is  essential  to 
wait  a  considerable  time  (four  or  five  weeks)  until  the  con- 
dition has  become  stationary  before  a  laminectomy  is  per- 
formed. 

2.  The  operation  is  contraindicated  in  the  presence  of 
pulmonary  or  abdominal  complications;  likewise  if  severe 
suppurative  processes  or  decubitus  is  present  near  the  site 
of  operation ;  also  if  the  cnsc  is  complicated  by  a  suppurative 
ascending  pyelitis. 

3.  Mild  infection  of  the  urinary  tract  and  granulating  bed 
sores  and  not  contraindications. 

4.  In  spite  of  the  small  clinical  material  presented  it  is 
evident  that  severe  direct  injuries  and  tangential  shots,  in 
contradistinction  to  indirect  injuries,  such  as  compression,, 
edema,  liquor  stasis,  and  local  inflammation,  are  hardly 
adapted  to  radical  surgical  intervention. 


Leva,  J.:  Injuries  of  the  Spinal  Cord  in  War  (tJber  Verletzuugen 
des  RiickenuiMrks  im  Kriege).  Miinchen.  med.  Wchnschr.,  1915, 
Ixii,  925. 

In  9  of  the  cases  observed  by  Leva  symptoms  of  complete 
transverse  lesion  predominated,  in  5  there  were  signs  of  a 
lesion  of  one-half  of  the  cord,  and  in  7  signs  that  indicated 
solitary  injuries  of  different  centers.  Of  the  patients  with 
signs  of  a  total  transverse  lesion  2  died  soon  after  they  were 
received,  1  of  an  ascending  meningitis  and  1  of  pyelone- 
phritis; the  condition  of  1  remained  unchanged,  in  1  the 
symptoms  gradually  improved  till  they  were  those  of  a  uni- 
lateral lesion,  in  2  a  spastic  paralysis  developed,  and  3  im- 
proved so  much  that  no  organic  symptoms  remained  except 
increased  reflexes. 

These  cases  show  that  symptoms  of  a  complete  transverse 
lesion  at  first  do  not  by  any  means  prove  that  there  is  actu- 
ally a  complete  severing  of  the  cord.  Shock  and  concussion 
have  caused  a  temporary  cessation  of  its  function,  which  is 
restored  in  time. 

Of  the  5  patients  with  unilateral  symptoms  2  improved 
markedly,  while  the  paralysis  only  improved  slightly  in  the 
other  2.  In  the  other  cases  the  course  varied ;  in  1  it  was  very 
favorable,  2  developed  cerebellar  symptoms,  1  developed 
pain  and  atrophy  of  the  right  arm,  which  did  not  improve 
much  even  after  laminectomy.  In  2  cases  of  injury  of  the 
neck  signs  of  lesion  of  the  medulla  developed,  including 
various  subjective  symptoms  and  paresthesias.  Injuries  of 
the  cervical  column  did  not  produce  such  serious  effects  as 


FOREIGN    WAR   LITERATURE.  291 

injuries  lower  down.  The  total  of  21  cases  after  six  months' 
observation  shows  2  deaths,  or  9.5  per  cent,  but  they  can  not 
be  regarded  as  closed,  for  secondary  signs  of  degeneration 
often  appear  a  long  time  after  the  injury. 


Perthes,  Goldstein,  Armour,  (xuillain,  and  Hull  all  incline  to  a 
someAvhat  radical  position.  It  is  interesting,  however,  to  note  the 
strong  tendency  to  qualify  their  statements,  thus  mirroi-ing  the 
uncertainty  with  which  one  approaches  these  graA'e  lesio]is. 

Perthes,   G.:   Laminectomy   in   Cases  with    Bullets   Lodged   in   the 
Spinal  Cord.  (Uber  Ijauiiuektouiie  liei  Steckscliiissen  des  Riickeu- 

mai'kes).     Beitr.  ,:.  l-Jin.  Chir.,  1915,  xevii,  TC. 

There  is  still  a  great  difference  of  opinion  as  to  the  proper 
course  to  pursue  in  gunshot  injuries  of  the  spinal  cord  : 
some  surgeons  advise  operation,  and  others  equally  skilled 
advise  against  it.  Perthes  considers  only  those  cases  in 
which  the  projectiles  remain  in  the  spinal  canal,  and  gives 
the  histories  of  six  such  cases  operated  upon  by  him.  Two 
of  these  patients  died  the  day  after  the  operation :  one  died 
later,  after  the  wound  had  healed;  one  recovered  from  the 
operation,  but  not  froju  the  paral^'^sis;  but  in  the  two  other 
cases  the  improvement  after  the  operation  was  so  marked 
that  there  is  every  reason  to  believe  it  will  be  complete. 

He  discusses  the  syniptoms  of  complete  and  partial  trans- 
verse section  of  the  spinal  cord  and  concludes  that  laminec- 
tomy should  be  performed  in  all  cases  where  there  is  only 
partial  section.  In  sucii  cases  the  sj^mptoms  are  often  due  to 
pressure  by  the  projectile,  and  recovery  after  operation  is  * 
remarkably  rapid  and  complete.  //  there  is  complete  trans- 
verse section  of  the  cord^  operation  is  uselSss,  hut  it  must 
he  home  in  mind  that  there  are  often  clinical  signs  of  com- 
plete section  tohen  anatomically  a  part  of  the  cord  is  pre- 
served; so  it  is  quite  possible  that  some  such  cases  may  be 
saved;  at  any  rate  tXe  operation  can  do  no  harm,  for  the 
patients  will  die  if  not  operated  upon.  The  operation 
should  be  performed  under  local  anesthesia  with  the  aid 
of  pantopon-scopolamine  or  scopolamine-morphine  anesthe- 
sia. In  the  cases  of  only  partial  section  of  the  cord  the 
operation  should  he  performed  at  once;  there  is  no  object  in 
waiting,  as  the  pressure  symptoms  will  only  grow  worse. 


Goldstein:  Gunshot  Injuries  of  the  Brain  and  Spinal  Cord  (Beobach- 
tungen  an  .Scliussverletzungen  des  Gehirns  und  Riickenmarks). 
Deutsche  med.  Wchmchr.,  1915,  xli,  215,  250. 

There  are  three  groups  of  such  injuries:  (1)  Those  that 
are  so  severely  injured  that  they  die  soon  afterwards;  (2) 
those  in  w^hich  the  symptoms  are  very  severe  at  first,  but 
improve  in  a  relatively  short  time  and  after  a  few  weeks 
almost  disappear;  (3)  those  in  which  the  symptoms  do  not 
improve,  and  in  spite  of  the  best  care  the  patients  die  after 


292  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

a  few  weeks.  Of  course  only  the  latter  two  classes  are  seen 
in  the  hospitals. 

In  injuries  of  the  spinal  cord  he  advises  more  frequent 
operation.  He  describes  two  cases  in  which  autopsy  showed 
that  operation  might  have  been  useful.  In  one  there  were 
bone  splinters  in  the  cord  that  might  have  been  removed, 
and  in  the  other  connective-tissue  adhesions  that  might  have 
been  freed  to  relieve  the  cord  from  compression. 

He  advises  operation  in  all  cases  where  there  are  evidences 
of  a  transverse  lesion  and  where  flaccid  paralysis  with  fail- 
ure of  reflexes  persists  for  some  time.  The  length  of  time 
before  operation  depends  in  part  on  the  patient's  general 
condition.  If  this  is  bad  and  there  are  marked  bladder 
disturbances  and  severe  decubitus,  not  more  than  three  weeks 
at  the  most  should  elapse.  Of  course  operation  may  be  in 
vain  if  the  cord  is  completely  severed,  and  there  is  no  way 
of  telling  absolutely  from  the  clinical  symptoms  whether 
this  is  true ;  but  the  prognosis  is  hopeless  in  these  cases  any- 
way and  no  harm  can  be  done^  whereas  by  operating  cases 
will  be  saved  in  which  there  is  any  possibility  of  cure.  Op- 
eration should  always  he  performed  in  cases  tohere  a  hullet 
can  he  seen  in  the  spinal  canal  in  the  rontgen  picture  and 
the  disturhances  do  not  improve. 


Armour,  D.:  Gunshot  Wounds  of  the  Spine;  Their  Surgical  Aspect. 

Lancet,  Lond.,  1916,  cxc,  770. 

The  author  divides  gunshot  wounds  of  the  spine  into  two 
classes:  (1)  Those  in  which  there  is  no  interference  with 
the  function  of  the  spinal  cord;  (2)  those  in  which  there 
is  more  or  less  interference  with  the  function  of  the  spinal 
cord  Avith  or  without  obvious  injury  to  the  vertebral  column. 

Injury  to  the  vertebral  column  may  be  followed  later  by 
effects  of  inflammatory  products — adhesions,  narrowing  of 
the  spinal  canal,  intra  or  extra  dural  clot,  etc. 

Immediate  injury  to  the  cord  may  be  caused  b}^:  (1)  The 
missile  passing  through  part  or  the  whole  of  the  cord; 
(2)  fractured  bone  causing  compression,  contusion,  lacer- 
ation, or  complete  division;  (3)  concussion. 

The  author  has  found  the  X  ray  to  have  only  confirm- 
atory value  in  localizing  bone  injury  and  foreign-body 
position. 

The  points  of  importance  arising  regarding  operative 
intervention  are:  (1)  Will  any  benefit  to  the  patient  result 
from  the  operation?  (2)  Will  his  life  be  endangered  by 
the  operation?      (3)  AVill  he  be  made  worse  by  operation? 

The  author  then  discusses  indications  for  operation  and 
urges  interference  under  proper  surgical  skill  and  asepsis  in 
all  cases  in  which  complete  section  has  not  taken  place,  pro- 
viding the  patient  is  in  a  fair  general  condition.  He  says: 
"  It  'is  unfair  to  the  patient  and  unfair  to  surgery  to  umit  on 
and  on  till  hope  gives  place  to  despair  and  then  call  in  a 
surgeon  as  a  last  resort  to  perform  the  impossihle.''^ 


FOREIGN    WAR  LITERATURE.  293 

Operation  is  therefore  indicated  (1)  to  relieve  pressure 
from  depressed  or  displaced  fragments  of  bone;  (2)  to  re- 
lieve pressure  from  blood  clot  or  from  extensive  hemor- 
rhage, either  extra  or  intra  dural;  (3)  to  relieve  pressure 
and  prevent  further  destruction  from  edema  by  enlarging 
the  constricted  bony  canal;  (4)  to  remove  the  danger  of 
pressure  from  exudate  and  inflammatory  thickening. 


Guillain,  G.,  and  Barre,  I.  A.:  Injuries  of  the  Spinal  Cord  in  War 

(Les  pkiies  de  la  iiKielle  T'lniiic'ie  par  blessures  de  guerre).    I'rcs.se 
DiM.,  1916,  p.  497. 

In  the  present  v^ar  injuries  of  the  cord  are  most  frequently 
due  to  shell  fire.  Of  the  authors'  cases  61  per  cent  were  due 
to  shells,  23  per  cent  to  bullets,  8  per  cent  to  shrapnel. 

In  addition  to  the  usual  symptomatology,  paraplegia,  dis- 
turbance of  muscular  tonus,  neuromuscular  contractility, 
abolition  of  reflexes,  etc.,  the  authors  have  observed  in  para- 
plegic patients  with  abolition  of  all  tendon  reflexes,  that 
after  percussion  of  the  rotulian  tendon  even  with  the  quad- 
riceps muscle  remaining  absolutely  inert,  there  is  a  more  or 
less  vivid  contraction  of  the  posterior  thigh  muscles,  most 
frequently  of  the  postero-externo  muscles  with  a  sometimes 
slight  flexion  movement  of  the  limb  which  gives  the  appear- 
ance of  what  has  been  termed  inversion  of  the  rotulian  reflex. 
This  is  a  true  reflex  and  may  be  aptly  termed  the  posterior 
tibiofemoral  reflex. 

While  sensory  painful  disturbances  are  lacking  in  the  ma- 
jority of  cord  injuries,  tactile  painful  anesthesia  is  most  fre- 
quently absolute  and  total.  Muscular  atrophy  is  sometimes 
extremely  rapid;  urinary  and  fecal  retentions  are  almost 
ahvays  present. 

In  the  authors'  opinion  a  description  of  the  general  symp- 
tomatology in  injuries  of  the  cord  is  a  chapter  still  ibo  be 
written,  as  it  is  not  to  be  found  in  any  text  on  neurology.  In 
the  beginning  for  the  first  few  days  the  patient  feels  rela- 
tively well  and  has  no  appearance  of  severe  injury.  The  two 
most  marked  symptoms  at  this  time  are  excessive  thirst  and 
insomnia.  Sooner  or  later  the  appetite  which  was  good  is 
lost,  loss  of  weight  is  rapid,  and  somnolency  is  almost  con- 
stant. 

Of  100  cases  in  the  authors'  service  the  mortality  was  80 
per  cent.  Of  the  other  20  evacuated  cases  several  are  known 
to  have  since  died,  and  the  authors  are  in  reality  only  cogni- 
zant of  4  cases  of  amelioration,  2  subsequent  to  surgical  inter- 
vention and  2  spontaneously. 

In  a  table  given  by  the  authors  it  is  seen  that  most  cases 
do  not  survive  three  weeks.  The  maximum  survival  observed 
57  days  in  a  case  of  lesion  of  the  eighth  dorsal  segment. 

What  are  the  real  causes  of  such  rapid  death  in  these  in- 
juries of  the  spinal  cord?  The  authors  believe  that  urinary 
and  pulmonary  infections  which  have  been  indicated  by  some 
as  the  cause  may  be  excluded.  Patients  injured  in  the  sacral 
or  dorsal  regions  usually  succumb  to  a  purulent  meningitis. 


294  WAE    SURGERY   OF    THE    is'ERVOUS   SYSTEM. 

but  the  principal  cause  appears  to  be  a  progressive  cachexia. 
The  causes  of  death  according  to  the  authors'  view  should  be 
classed  as:  Purulent  meningitis;  disturbance  of  the  sym- 
pathetic nervous  system  of  the  digestive  tract,  abdominal  vis- 
cerai ;  and  vascular  glands ;  cachexia  through  default  of  as- 
similation; anemia  of  the  cerebral  centers.  If  the  lesion  is 
very  grave,  the  sympathetic  nerve  trouble  is  at  a  maximum. 

There  is  little  difficulty  in  diagnosis.  The  only  question  is 
one  of  differentiation  between  GOTniylete  and  incomplete 
section^  or  a  heniatomyelia^  a  medullary  disturhance^  or  a 
compression. 

In  complete  section  (anatomic  or  physiologic)  motor  para- 
plegia is  complete ;  urinary  retention  absolute ;  all  the  tactile 
painful,  thermic,  and  vibratoi-y  reflexes  are  abolished ;  all  the 
tendon  reflexes  are  abolishecl.  In  incomplete  section  the 
abolition  of  sensations  (especially  vibratory)  is  not  absolute 
nor  global,  even  segmental  attitudes  may  be  preserved. 
Traumatic  hematomj^elia  is  almost  alwaj^s  accompanied  by  a 
sanguinary  suffusion  in  the  piamater-arachnoidean  space 
which  may  be  demonstrated  by  lumbar  puncture. 

The  authors  think  that  in  all  spinal  injuries  radiography 
is  indispensable  not  only  to  show  the  nature  of  the  osseous 
lesions,  but  also  to  determine  the  rachidian  or  extrarachidian 
situation  of  the  projectile. 

Treatment  consists  in  the  association  of  neurology  and 
surgery.  Every  spinal  wound  should  he  explored  as  quickly 
as  possible.,  the  entry  orifice  stripped,  the  wound  disinfected, 
and  the  bone  examined.  All  fragments  should  be  removed. 
The  authors  discountenance  the  use  of  antiseptics  which  may 
be  hurtful  to  the  exposed  medullary  tissues.  Manipulation 
in  this  region  should  be  as  delicate  as  possible.  Chloroform 
or  ether  as  anesthetics  are  very  badlj^  supported  and  the 
authors  prefer  a  local  anesthetic. 

If  on  a  prior  examination  there  is  no  evidence  that  the 
dura  mater  is  opened,  the  absolute  rule  of  surgery  not  to 
open  it  must  be  respected.  But  if  it  is  open  prolonged  lavage 
with  warm  physiologic  serum  at  slight  pressure  is  the  only 
treatment.  Any  attempts  at  suturing  according  to  the  au- 
thors' experience  is  absolutely  useless. 

The  question  of  removal  of  the  projectile  is  open  to  dis- 
cussion. If  it  is  situated  at  the  back  or  at  the  sides  of  the 
cord  or  if  it  is  intramecluUar,  it  should  be  removed.  When 
the  projectile  has  traversed  the  cord  causing  perhaps  only  a 
partial  section  and  is  lodged  in  a  vertebral  appendage  its  re- 
moval although  possible  from  the  surgical  viewpoint  is  a 
matter  of  opinion,  because  in  such  event  new  lesions  will  be 
created  which  may  turn  an  incomplete  section  into  a  com- 
plete one. 

Frangenheim,  P.:  Gunshot  Injuries  of  the  Spinal  Column  and  Spinal 
Cord  ( Schussverletzungeii  des  Rueekenmarks  und  de  der  Wirbel- 
sauele).    Muenchen.  mecl.  Wchnschr.,  1915,  Ixii.  1473. 

Frangenheim  has  operated  in  25  cases:  of  these,  9  have 
died  and  the  others  were  discharged  after  four  to  six  weeks' 


FOREIGN    WAR   LITERATURE,  295 

treatment,  some  of  them  improved,  and  some,  in  whom  there 
nas  only  partial  paralysis,  practically  well.  There  is  no 
way  of  making  a  certain  diagnosis  as  to  the  extent  of  a 
spinal  injury.  It  is  very  difficult  to  localize  projectiles  accu- 
rately. Fractures  of  the  spinous  processes  are  hard  to 
demonstrate  roentgenologically,  and  small  fragments 
broken  off  from  the  bone  and  compression  of  the  cord  from 
bone  fragments  can  not  be  so  demonstrated.  As  a  rule 
splintering  of  the  bone  can  not  be  demonstrated  till  the 
muscles  have  been  stripped  off  from  the  processes. 

Contusion  of  the  cord,  compression  of  the  cord,  and  com- 
plete transverse  severing  of  it  all  give  the  clinical  picture  of 
complete  paralysis  with  loss  of  control  of  the  bladder  and 
rectum.  It  can  not  be  determined  from  the  reflexes  whether 
the  cord  is  completely  severed  or  not;  therefore  the  author 
advises  exploratory  laminectomy  in  all  cases;  further  treat- 
ment depends  on  the  findings.  Early  operation  is  generally 
preferred  to  expectant  treatment. 

Lumbar  puncture  over  the  site  of  the  injury  is  of  consid- 
erable value  in  diagnosis.  Frangenheim  admits  that  his 
numbers  are  small  and  that  later  complications  may  3^et 
appear  in  some  cases,  but  he  is  convinced  that  exploratory 
laminectomy  is  the  best  method  of  procedure  in  these  cases. 


Hull,  A.  J.:  Treatment  of  Gunshot  Wounds  of  the  Spine.     Brit.  M. 
J.,  1916,  i.  .j77. 

To  be  successful  spinal  operations  must  be  performed  at 
an  earl}^  stage  before  any  vital  changes  have  occurred  in  the 
cord.  Bi/  delaying  operative  interference  cases  lose  their 
chance  of  recovery  either  hy  the  sepsis  spreading  or  hy  pres- 
sure on  the  nerve  tissue^  causing  these  vital  changes  to  take 
place. 

It  would  appear  justifiable  to  operate  upon  spinal  injuries 
when  the  X-ray  localization  shows  a  foreign  body  present  in 
an  accessible  position,  and  especially  when  there  is  evidence 
of  some  remaining  conductivity  of  the  cord,  as  here  the  re- 
moval of  pressure  may  be  followed  by  great  improvement. 
Pain  in  some  spinal  lesions  is  so  intense  that  an  operation 
is  justifiable,  whatever  the  lesion  of  the  cord. 

Three  lines  of  treatment  are  indicated:  (1)  Prevention  of 
sepsis,  (2)  removal  of  gross  pressure  upon  the  spine,  and 
(3)  the  prevention  of  complications  which  threaten  life. 


Marie  and  Roussy  draw  attention  to  the  important  question  of  after 
care  of  spinal-injury  cases,  furnishing  specific  details  for  the  avoid- 
ance of  decubitus.  Under  this  head  it  should  be  noted  that  verbal 
reports  have  reached  this  country  that  in  many  of  the  hospitals 
abroad  the  spinal-injury  cases  are  not  catheterized  or  irrigated. 
The  bladder  is  allowed  to  empty  itself  by  overflow. 


296  WAR  SURGERY   OF    THE    NERVOUS  SYSTEM. 

Marie,  P.,  and  Roussy,  G.:  Possibility  of  Preventing  Decubitus  in 
Wounds  of  the  Spinal  Cord  (.Sur  la  possibilite  de  preveuir  la 
formation  des  escarres  dans  les  traumatismes  de  la  moelle 
gpiniere  par  blessures  de  guerre).  Bull.  Acad,  de  med.,  Par., 
1915,  Ixxiii,  609. 

Though  the  prognosis  in  injuries  of  the  spinal  cord  is 
grave,  it  is  by  no  means  so  hopeless  as  it  has  usually  been 
considered.  Paraplegias  often  show  a  remarkable  tendency 
to  spontaneous  recovery.  On  account  of  the  feeling  of  hope- 
lessness in  these  cases  precautions  have  been  neglected  that 
might  have  improved  the  condition  of  the  patients. 

It  has  always  been  held  that  decubitus  was  caused  directly 
by  the  injury  of  the  spinal  cord  itself,  and  that  therefore 
it  could  not  be  prevented.  This  is  untrue,  and  bedsores  can 
and  should  be  prevented  in  all  cases.  The  patient  can  not 
change  his  position  on  account  of  the  paraplegia,  so  that 
the  same  parts  have  to  support  the  weight  of  his  body  con- 
stantlj'.  Prolonged  compression  interferes  with  the  circu- 
lation in  these  parts.  Moreover,  because  of  the  loss  of  sen- 
sation the  patient  does  not  have  the  normal  inclination  to 
change  his  position.  These  factors,  however,  only  produce 
a  dry  eschar  that  is  not  at  all  serious,  but  because  of  the 
lack  of  continence  they  become  soaked  with  urine  and  then 
infected.  That  this  is  the  cause,  and  not  the  spinal  injury,, 
is  shown  by  the  fact  that  the  site  of  the  decubitus  has  no 
relation  to  the  level  of  the  cord  injury.  Wherever  the  cord 
injury  may  be,  the  bedsore  occurs  at  the  points  of  pressure 
on  the  sacrum. 

To  prevent  the  formation  of  these  sores  the  bladder  and 
rectum  should  be  examined  in  every  case  of  injury  of  the 
spinal  cord.  To  avoid  soiling  with  urine  a  retention  cathe- 
ter should  be  inserted.  The  bowels  may  be  locked  for  a 
few  days  by  the  administration  of  opium,  and  the  skin  may 
be  protected  with  talcum  powder  or  vaseline.  The  patient 
may  be  placed  on  air  cushions  while  being  transported.  If 
he  has  been  neglected  during  transpoi'tation  and  arrives  at 
the  base  hospital  with  bedsores  already  developed,  they  maj 
be  cured  if  he  is  given  the  greatest  care  and  the  sores  dressed 
once  or  tAvice  a  day  with  phenolized  powders.  Nurses 
should  be  instructed  to  change  the  patient's  position  every 
hour  during  the  day  and  every  two  hours  at  night.  Infec- 
tions of  the  bladder  and  urethra  should  be  treated  with  ir- 
rigations of  potassium  permanganate  or  nitrate  of  silver. 


The  two  following  abstracts  by  von  Eiselsberg  and  Ascher  & 
Licen  represent  the  latest  authoritative  German  opinion  on  gimshot 
injuries  of  the  spine.  These  two  abstracts  are  grouped  separately 
merely  by  reason  of  their  late  date. 


FOREIGN    WAR   LITERATURE.  297 

Von  Eiselsberg:  Report  on  Gunshot  Injuries  of  the   Spinal  Cord. 

(Ueber  ScJiiisHe  insbosoiidere  Spaetchii-uryie. )  Report  lo  the  Sec- 
ond German  Surgical  Congress.  Beitraege  zur.  Klin.  CItir.  Bd.  v. 
Hft  1.    Kriegschirvrf/iftche  Hefte.    1916. 

The  problem  of  transportation  of  fresh  injuries  of  the 
spinal  cord  is  most  important.  In  many  cases  it  is  desirable, 
if  possible,  that  the  wounded  lie  on  the  stretcher  upon  which 
they  are  first  placed  until  they  reach  their  ultimate  destina- 
tion. This  is  doubly  true  with  patients  suffering  from  spinal 
cord  injury.  Not  only  that,  but  they  should  be  fixed  to  the 
bar  in  order  to  avoid  alteration  of  position  and  in  order  to 
guard  against  jolting.  Special  spiral  springs  should  be  put 
under  the  legs  of  the  stretcher  and,  best  of^all,  the  kind  of 
spring  used  which  can  be  screwed  to  the  floor  of  the  carriage. 

Perthes  has  warmly  recommended  early  operation  for 
spinal  cord  injury.  This  does  not  correspond  with  the 
opinion  of  von  Eiselsberg,  who  operates  early  only  in  very 
exceptional  cases.  He  says,  further,  that  it  is  usually  not 
possible  to  operate  until  the  patients  reach  the  base  hosiptals. 

Speaking  of  the  necessity  for  catheterization,  it  is  even 
more  true  in  war  than  in  peace  time  that  it  is  practically 
impossible  to  keep  the  bladder  free  from  bacteria;  particu- 
larly during  transportation  is  this  true.  In  order  to  avoid 
danger  of  infection  through  repeated  catheterization  or 
permanent  catheter,  von  Eiselsberg  recommends  a  supra- 
pubic cystostomy. 

As  soon  as  the  patient  reaches  the  base  hospital,  it  is  most 
important  of  all  to  determine  the  location  and  the  extent  of 
the  spinal  cord  injury.  In  cases  where  one  recognizes  a  frac- 
ture and  where  one  finds  the  projectile  in  the  spinal  canal, 
he  should  do  an  early  operation,  for  the  reason  that  a  long- 
continued  pressure  on  the  spinal  cord  can  produce  a  second 
permanent  degeneration.  A  second  indication  for  an  early 
operation  is  a  severe  infection  with  high  fever  and  pus 
discharge. 

A  very  important  part  of  the  treatment  lies  in  protecting 
the  patient  against  the  development  of  bedsores.  These  may 
develop  very  early  and  very  rapidly,  even  during  the  trans- 
portation from  the  field. 

Injuries  of  the  spinal  cord  call  for  two  classifications. 
The  first  classification  is  according  to  anatomical  injury; 
the  second  according  to  the  symptoms.  The  pathological 
anatomy  teaches  that  several  injuries  may  be  produced  : 

1.  Heniorrhage  into  the  dural  sheath,"  and  through  this 
compression  symptoms.  Hemorrhages  may  be  completely 
absorbed.  When  not  completely  absorbed  they  organize, 
and  this  may  result  in  pachymeningitis,  or  the  so-called 
"  meningitis  serosa  circumscripta."  The  regression  of  a 
traumatic  hematoma  is  quite  analogous  to  the  traumatic 
cysts  seen  over  the  brain  cortex. 

2.  Projectile  or  bone  fragments  may  cause  pressure  on  the 
spinal  cord. 

3.  At  the  time  of  injury  an  irreparable  damage  may  have 
been  done  to  the  spinal  cord. 


298  WAR   SURGERY    OF    THE    NERVOUS    SYSTEM. 

Obviously,  combinations  of  these  three  findings  usually 
occur,  and  the  paralysis  may  be  caused  partially  by  a  hema- 
toma, partially  by  an  impinging  vertebra  or  fragment  of 
bullet,  and  partially  by  a  cutting  of  the  spinal  cord  by  bone 
fragment  or  projectile.  The  diagnosis  upon  anatomic  con- 
siderations is  usually  purely  conjectural. 

According  to  the  symptomatology  there  are  three  groups, 
one  with  complete  transverse  lesions,  in  which  there  is  abso- 
lute flaccid  paralysis  of  the  parts  below  the  site  of  spinal- 
cord  injury,  with  loss  of  reflexes  and  complete  disturbance  of 
sensation.  This  picture  of  complete  lesion  can  be  caused  by 
compression,  either  from  vertebra  or  projectile.  Second, 
there  is  spastic  paraplegia  where  there  is  paralysis  with  in- 
creased reflexes,  clonus,  positive  Babinski,  and  this  is  re- 
garded generally  as  compression  syndrome.  In  these  cases 
laminectomy  promises  a  better  outlook.  A  third  group  of 
partial  spinal-cord  lesions  is  divided  into  two  forms:  (a) 
The  Brown-Sequard  type  and    (J?)   the  spinal  hemiplegia. 

4.  Lesions  of  the  cauda.  Here  the  prognosis  is  good,  ex- 
cept for  the  bladder  troubles. 

It  often  happens  that  there  is  complete  loss  of  control  of 
the  bladder  when  the  injury  of  the  spinal  cord  is  not  com- 
plete, and  the  kind  and  the  location  of  the  spinal-cord 
lesion  seems  to  bear  no  relationship  to  the  kind  and  the  du- 
ration and  the  prognosis  of  bladder  disturbances.  The 
chief  danger  in  these  bladder  disturbances  is  the  bladder 
"and  kidney  infection.  The  danger  of  ascending  infection 
is  the  gravest  of  all  dangers  in  spinal-cord  injuries,  except 
those  where  the  injury  is  above  the  phrenic  nerve. 

Now  comes  the  grave  question  for  the  surgeon  to  decide — 
whether  and  when  operation  shall  be  done.  The  symptoms 
are  often  confusing  and  differential  diagnosis  hetween  the 
hind  of  injuries  can  not  he  made^  particularly  since  combi- 
nations often  occur/  hut  in  order  to  avoid  operating  upon 
cases  tvhich  vould  improve  xoithout  operation^  von  Eisel- 
herg  has  made  a  practice  not  to  operate  until  8  or  10  loeeks 
after  the  injury^  meaninhile  ohserving  symptoms  most  care- 
fully. When  there  is  the  slightest  improvement  he  post- 
pones operation  and  operates  only  when  the  condition  re- 
mains stationary  or  ivhere  sym^ptoms  grow  more  pronounced. 
As  hefore  mentioned,  he  makes  exception  in  those  cases 
where  impinging  hone  fragments  or  projectiles  can  he  rec- 
ognized. 

Ether  is  the  anesthetic  of  choice,  and  the  important  points 
in  technic  are  care  to  avoid  producing  further  injury  and 
very,  very  wide  exposure,  and  opening  of  the  dural  sac. 
The  treatment  before  as  Avell  as  after  the  operation  de- 
mands the  most  careful  and  conscientious  nursing.  Patients 
should  be  kept  on  water  cushions  or  water  mattresses.  The 
water  mattress  is  \Qvy  pleasant  to  the  patient,  and  by  its 
use  bedsores  can  be  avoided.  Very  often  from  large  bed- 
sores infectioji  spreads  and  a  certain  cachexia  develops 
which  complicates  the  picture.     It  is  also  of  very  much  im- 


FOREIGN    WAR   LITERATURE.  299 

portance  from  the  beginning  to  avoid  atrophy  and  contrac- 
tures by  massage,  electricity,  and  careful  passive  movement. 
Forty  cases  of  spinal-cord  injury  were  operated.  Of 
these,  10  were  distinctlj^  improved,  8  were  slightly  im- 
proved, 7  were  unimproved,  2  died  soon  after  the  operation, 
and  7  died  eventually.  In  all,  there  were  9  deaths  and  24 
improved  cases  out  of  40  operative  cases.  In  73  cases  not 
operated  there  were  36  deaths  and  35  cases  showing  im- 
provement. This  shows  much  better  results  in  the  oper- 
ative cases,  in  spite  of  the  fact  that  the  operated  cases  were 
more  severe  and  were  cases  in  which  no  spontaneous  im- 
provement was  noted. 


Ascher  and  Licen:  Gunshot  Wounds  of  the  Spine  and  their  Treat- 
ment (ilber  Sehussverletzuiigeu  cles  iiiickeuniarks  und  Dereu 
Operative  Behandlung).  Beitrdge  zur  Klmsche  Chirurgie. 
{Kriegschirurgischcs  Heft  XX XI 11.)     Mai\,  1917.    P.  .521. 

Ascher  and  Licen  report  35  cases  of  gunshot  of  the  spinal 
cord,  which  they  treated  for  several  months.  Tw^enty  of  the 
35  cases  were  through  and  through ;  in  15  cases  the  bullet  re- 
mained in  the  body.  In  only  1  case  was  the  bullet  free  in 
the  spinal  canal.    The  mortality  was  25  per  cent. 

The  diagnosis  of  spinal-cord  injuries  has  three  points  to 
consider — the  location  of  the  lesion,  the  degree  of  the  lesion, 
and  the  kind  of  lesion.  In  localizing  the  injury  the  path  of 
the  bullet,  as  estimated  b}^  the  entrance  and  exit  wounds, 
gives  a  valuable  clue,  although  it  should  be  remembered 
that  a  projectile  does  not  always  traverse  a  straight  line, 
but  may  be  deflected  by  the  spinal  column,  and  also  that  the 
wounds  often  lie  in  a  movable  region,  as,  for  instance,  the 
shoulder,  and  that  it  is  impossible  to  tell  in  what  position 
the  patient  Avas  at  the  moment  of  his  injury.  Deformities  in 
the  spinal  column  did  not  help  in  localizing  the  lesion  in 
these  cases,  and  while  sensitiveness  over  the  spinal  processes 
was  present  it  extended  also  to  uninjured  vertebrae.  Crepi- 
tation was  never  encountered. 

X-ray  examinations  were  in  large  majority  of  cases  un- 
satisfactory. The  neurological  examination  is  to  be  most 
relied  upon  in  establishing  the  exact  location  of  injury.  It 
is  to  be  remarked  that  the  neurological  findings  indicated 
an  injury  somewhat  higher  than  actually  found,  ordinarily 
two  or  three  segments  of  the  cord.  This  is  not  only  during 
the  first  days,  but  also  later  and  possibly  permanently  so. 

The  degree  of  the  lesion  can  usually  be  determined  within 
the  first  few  days,  certainly  within  the  first  two  or  three 
weeks,  and  chiefly  through  exact  and  oft-repeated  examina- 
tions.   The  kind  of  lesion  can  seldom  be  determined  upon. 

Spinal  puncture  did  not  help  these  cases.  In  discussing 
operative  treatment,  in  12  of  the  35  cases  operation  was  con- 
sidered indicated.  In  1  of  the  12  operations  there  was 
complete  recovery.  In  1  there  was  very  marked  improve- 
ment; 4  were  uninfluenced  by  the  operation;  3  improved 
very  slowly  after  the  operation,  although  at  operation  no 


300  WAR   SUKGEEY    OF    THE    XERVOUS    SYSTEM. 

spinal-cord  injury  was  found,  and  it  was  questionable 
AThether  improvement  w^as  due  to  the  operation ;  3  cases  died 
within  the  first  10  days  after  laminectomy. 

Laminectomy  was  performed  under  local  anesthesia,  with 
the  exception  of  one  case.  The  Avound  was  closed  tightly. 
No  case  of  meningitis  deA-eloped.  Primary  healing  occurred 
in  each  instance. 

Operation  should  be  undertaken  at  the  \'ery  earliest  oppor- 
tunity in  all  cases  in  which  there  is  compression  of  the  spinal 
cord,  without  consideration  of  the  severity  of  symptoms. 
Operation  should  also  be  undertaken  in  those  cases  in  which 
X-ray  examination  shows  a  possibility  of  bone  splinters 
lying  Avithin  the  spinal  canal  and  in  those  cases  in  which 
there  is  a  sudden  increase  of  paralysis.  In  the  A^ast  majority 
of  cases  in  which  nervous  examination  shows  a  complete 
lesion  of  the  cord  operation  is  superfluous.  Other  authorities 
are  quoted  who  recommend  operation  only  when  there  is  no 
improvement  after  a  few  weeks'  observation. 


CHAPTER  III. 


PERIPHERAL  NERVES. 


Part  1. 
DISEASES  OF  THE  PERIPHERAL  NERVES. 

By  GoRuoN  M.  Holmes,  M.  D. 
[From  OsLER's  Modern  Medicine,  Vol.  V,  Chap.  XIV.     Published  by  Lea  &  Febiger.] 

The  symptoms  of  disease  of  the  peripheral  nerves  may  be  classified 
as  they  result  from  disturbance  of  the  functions  of  those  fibers  which 
convey  impulses  to  the  muscles,  of  those  which  carry  the  sensory 
impressions  centralward,  and,  finally,  of  the  fibers  which  are  more  im- 
mediately^ concerned  with  the  nutrition  of  the  tissues,  either  directly 
or  as  part  of  the  mechanism  for  the  local  regulation  of  the  blood 
stream.  There  are,  however,  but  few  nerves  in  the  body,  excepting  the 
cranial  nerves,  which  are  either  entirely  sensory  or  entirely  motor. 
The  consequence  is  that  when  any  nerve  is  severely  injured,  both  sen- 
sory and  motor  symptoms  and,  probably,  in  addition,  nutritive  or 
trophic  changes  result.  It  is  by  the  extent  and  distribution  of  these 
symptoms  that  the  localization  of  the  disease  can  be  determined. 
If,  however,  the  lesion  or  the  disease  of  a  mixed  nerve  is  partial  or 
incomj:)lete.  the  functions  of  the  different  sets  of  fibers  may  suffer 
unequally;  the  general  experience  is  that  in  incomplete  lesions,  as 
those  due  to  compression,  the  sensory  suffer  much  less  than  the  motor 
fibers,  or  sensor}^  symptoms  nia.j  be  absent,  although  the  muscles 
supplied  by  the  nerve  are  completely  paralyzed.  Luderitz  showed 
experimentally  that  the  conductivity  of  the  motor  fibers  is  lost  earlier 
than  that  of  the  sensory  fibers  when  a  mixed  nerve  is  subjected  to 
slowly  increasing  pressure.  Evidence  of  trophic  or  vasomotor  dis- 
turbance is,  as  a  rule,  little  apparent  in  partial  lesions. 

Motor  symptoms. — The  symptoms  which  immediately  follow  the 
complete  interruption  of  the  motor  nerve  fibers  that  supply  a  muscle 
are  complete  paralysis  of  both  reflex  and  volitional  contraction  of 
that  muscle,  loss  of  its  tone,  and,  later,  atrophy,  changes  in  the  char- 
acter of  its  response  to  electrical  stimulation;  and,  finally,  if  recov- 
ery does  not  take  place,  contracture,  owing  to  secondary  fibrosis. 
These  features  distinguish  lower  motor  neurone  or  spino-muscular 

301 


302  WAR   SURGERY   OF    THE    NERVOUS   SYSTEM. 

paralysis  from  paralysis  due  to  disease  in  the  upper  motor  or  cerebro- 
spinal neurones.  In  the  latter  condition  movements,  not  muscles  as 
such,  are  paralyzed,  and  the  distribution  of  one  or  more  peripheral 
nerves ;  secondly,  the  tone  of  the  paralyzed  muscles  is  increased,  not 
diminished  or  lost;  that  is,  the  paralysis  is  spastic  and  not  flaccid, 
and  the  reflexes  Avhich  are  dependent  on  the  tone  of  the  muscle,  as 
the  knee  jerk,  are  more  active  than  normal  instead  of  being  abol- 
ished; thirdly,  the  paralyzed  muscles  do  not  atrophy,or  atrophy  only 
to  a  much  less  degree ;  and,  finally,  there  is  no  change  in  the  nature 
of  their  response  to  electrical  stimulation. 

The  amount  of  loss  of  power  in  the  muscles  naturally  depends  on 
the  degree  of  the  injury  of  the  nerve;  when  there  is  complete  inter- 
ruption of  its  structure  or  loss  of  its  function  the  paralysis  neces- 
sarily complete.  When  the  lesion  of  the  nerve  is  incomplete  another 
factor  must  be  considered,  namely,  the  rate  of  its  evolution,  as  when 
the  disease  is  of  sudden  or  rapid  onset  the  symptoms  may  be  consid- 
erably greater,  for  a  time  at  least,  than  those  produced  by  a  similar 
lesion  which  has  developed  slowly.  A  muscle  that  receives  its  motor 
fibers  from  more  than  one  nerve  is  not  completely  paralyzed  by  even 
a  complete  lesion  of  one  of  them. 

The  normal  tone  or  tension  of  muscles  is  dependent  on  the  integ- 
rity of  the  peripheral  reflex  arc,  which  consists  of  the  afferent  fibers 
from  the  muscle  that  enter  the  cord  by  the  dorsal  spinal  roots  and 
terminate  by  synapsis  around  the  cells  of  the  corresponding  motor 
neurones  in  the  ventral  horn,  and  of  the  peripheral  motor  neurones. 
When  this  arc  is  broken  in  any  place  the  muscles  immediately  lose 
their  tone.  The  atonia  may  be  recognized  by  loss  of  the  normal  con- 
tour of  the  muscles,  if  this  is  easily  visible;  by  their  softness  and 
flabbiness  to  touch,  and  by  the  lack  or  diminution  of  the  resistance 
which  they  normally  offer  to  stretching,  and  consequently  the  excess 
of  mobility  to  passive  movement  of  the  joint  at  which  they  act. 

The  deep  reflexes  or  tendon  jerks  are  dependent  on  the  mainte- 
nance of  the  muscle  tone,  and  it  is  by  these  so-called  reflexes  that 
this  variety  of  tone  in  the  muscles  is  most  easily  measured.  Their 
disappearance  or  abolition  is  consequently  an  indication  of  the  dimi- 
nution or  disappearance  of  the  tone  of  the  muscles  concerned  and  not 
of  their  paralysis  alone.  The  knee  jerks  may  disappear  early  in  the 
toxic  affections  of  the  peripheral  nerves  before  there  is  any  demon- 
strable evidence  of  either  motor  or  sensory  paralysis;  and  during 
recovery  from  such  conditions,  or  after  regeneration  of  degenerated 
nerves,  they  may  be  absent  when  the  recovery  of  power  is  apparently 
complete.  The  diminution  or  loss  of  tone,  as  measured  by  the  deep 
reflexes,  is  the  most  sensitive  guide  to  any  interference  with  the  nor- 
mal function  of  the  peripheral  nervous  system. 


DISEASES   OF   PERIPHERAL   NERVES.  303 

Atrophy  of  the  muscles  supplied  by  the  affected  motor  fibers 
is  one  of  the  most  prominent  symptoms;  this  is  due  to  degeneration 
or  regression  of  the  muscle  fibers  owing  to  loss  of  the  trophic  influ- 
ence which  the  motor  nerves  normally  exert  on  them.  It  is  recogniz- 
able b,y  a  diminution  in  the  size  of  the  muscle  and  by  its  soft  and 
structureless  consistence.  The  latter  symptom  is  frequently  neg- 
lected, but  it  may  prove  valuable,  especially  in  children,  in  whom 
it  is  not  easy  to  detennine  the  distribution  of  an  atrophic  paralysis 
by  merely  noting  the  movements  which  can  not  be  performed;  here 
by  touch  alone  we  may  pick  out  the  affected  muscles.  Muscular 
atrophy  is  generally  recognizable  within  two  or  three  weeks  after  a 
complete  interruption  of  a  motor  nerve,  and  increases  rapidly  from 
this  time  until  few  if  any  fibers  remain.  When  the  nerve  lesion  is 
incomplete,  the  atrophy  corresponds  closely  with  the  degree  of  pa- 
ralysis; in  other  w^ords,  the  conducting  power  and  trophic  function 
of  the  peripheral  motor  nerves  are  lost  together.  When  the  lesion 
of  the  nerve  is  very  slowly  progressive  the  muscular  atrophy  is 
generally  less  prominent  than  the  paralysis. 

Coincident  with  the  atrophy  of  the  fibers  of  the  wasting  muscle 
an  increase  and  proliferation  of  its  connective  tissue  occur.  If  the 
muscular  atrophy  attains  severe  degrees,  and  if  regeneration  does 
not  soon  set  in,  this  new  connective  tissue  slowly  undergoes  fibrosis 
and  the  muscle  is  converted  into  a  firm,  inelastic  band.  The  contract- 
ing fibrous  tissue  may  produce  contractures  and  deformities.  Fur- 
ther, for  the  recovery  of  function  it  is  necessary  that  the  muscle 
fibers  should  regenerate,  and  regeneration  must  be  evidently  seriously 
interfered  witli  by  the  presence  of  dense  and  contracted  fibrotic  tissue. 
The  condition  of  the  muscles  and  the  changes  they  undergo  are  there- 
fore as  important  as  the  changes  in  the  affected  nerves. 

One  of  the  most  valuable  signs  in  disease  of  a  peripheral  motor 
nerve  is  changes  in  the  electrical  excitability  of  the  nerve  and  of  the 
muscles  it  supplied.  Muscular  contraction  can  be  normally  ob-' 
tainecl  by  either  faradic  or  galvanic  stimulation  of  the  motor  nerve 
fibers  which  supply  it.  Two  or  three  days  after  section  of  a  nerve 
the  excitability  of  its  peripheral  portion  is  diminished,  and  after  a 
period  of  six  to  eight  days  the  excitability  is  lost  with  the  secondary 
degener-ation  of  the  nerve.  The  most  characteristic  changes  are  ob- 
served on  direct  stimulation  of  the  muscle;  they  compose  what  is 
known  as  the  reaction  of  degeneration  (R.  D.)  and  usually  appear 
form  the  eighth  or  tenth  day  after  section  of  the  nerve.  It  must  be 
mentioned  that  according  to  Sherren  increased  excitability  to  the 
galvanic  current  is  found  only  when  the  lesion  of  the  nerve  is  in- 
complete. After  some  months,  if  recovery  has  not  set  in,  the  reaction 
of  the  muscles  to  the  galvanic  current  diminishes  slowly  and  finally 
disappears. 


304  WAR  SURGERY   OF   THE   NERVOUS  SYSTEM, 

In  every  case  of  peripheral  paralysis  it  is  important  to  test  the 
electrical  excitability  of  every  portion  of  the  nerve  and  muscle  that 
can  be  reached.  It  occasionally  happens  when  there  is  a  local  lesion 
in  the  nerve  that  muscular  contractions  can  be  obtained  by  stimula- 
tion below  the  lesion,  but  not  from  above  it;  the  lesion  may  block 
the  conduction  of  impulses  without  leading  to  secondary  degenera- 
tion of  the  peripheral  portion  of  the  fiber.  On  the  other  hand, 
regenerating  nerves  may  be  excitable  only  from  above  the  lesion ;  the 
regenerated  portion  is  for  a  time  inexcitable  to  stimuli  which  it  can 
conduct.  This  may  depend  on  the  absence  of  a  myelin  sheath  (Erb). 
When  the  lesion  is  unilateral  the  excitability  of  both  nerve  and 
muscle  msij  be  compared  with  those  of  the  normal  side ;  when  both 
sides  are  paralyzed  the  irritability  should  be  compared  with  those 
of  a  normal  person,  or  the  tables  prepared  by  Stintzing  to  show  the 
normal  limits  of  excitability  may  be  used. 

Ghilarducci's  distal  reaction  is  also  a  valuable  test ;  the  indifferent 
electrode  is  placed  on  the  neck  or  back,  the  other  distal  to  the  in- 
sertion of  the  degenerated  muscle;  then  on  closure  of  the  current  a 
contraction  of  this  is  obtained  by  a  weaker  current  than  suffices  for 
the  unaffected  muscles. 

Symptoms  of  irritation  of  motor  fibers  are  much  less  frequently 
met  with  in  diseases  of  the  peripheral  than  of  the  central  nervous 
system.  Spasm,  either  tonic  or  clonic,  and  cramps,  when  due  to 
irritation  of  the  peripheral  neurones,  are  generallj^  reflex  in  origin 
and  arise  from  excitation  of  the  sensory  fibers.  Occasionally,  how- 
ever, intermittent  or  tonic  spasm  may  result  from  irritation  of  a 
motor  nerve  by  a  neighboring  focus  of  inflammation  or  by  a  foreign 
body,  but  even  here  it  is  difficult  to  exclude  its  reflex  origin.  True 
reflex  spasms  are  much  more  frequent;  the  involuntary  facial  move- 
ments which  often  accompany  trigeminal  neuralgia,  and  even  irrita- 
tion of  the  cornea,  are  of  this  nature.  The  fixation  of  painful  joints 
by  the  tonic  contraction  of  the  surrounding  muscles  is  also  due  to 
irritation  of  the  sensory  fibers  which  reflexly  excite  the  correspond- 
ing motor  neurones  to  excessive  tonic  activity;  the  sensory  impulses 
ma}^,  if  sufficiently  intense,  spread  to  wider  reflex  centers  in  the  cord. 
The  potency  of  sensory  impulses  from  the  peripher^^  in  the  causation 
of  spasm  is  illustrated  by  the  severe  spasms  met  with  in  strychnine 
poisoning  and  in  tetanus;  both  these  poisons  only  transmute  an  in- 
hibitor}^ effect  into  an  excitation  effect  in  the  spinal  reflex  centers 
(Sherrington),  and  the  spasms  or  convulsions  are  always  directly 
due  to  a  stimulus  from  the  periphery.  Cramp  of  a  muscle  may  be 
occasionally  due  to  influences  that  affect  its  fibers  directly,  as  poisons 
like  veratrine ;  venosity  of  the  blood  may  also  predispose  to  or  cause 
spasms. 


DISEASES   OF   PEEIPHERAL   NERVES.  305 

Some  forms  of  muscular  atrophy  are  characterized  by  the  occur- 
rence of  fibrillation  or  intermittent,  more  or  less  rhythmical  Avavelike 
contractions  of  some  of  the  fibers  of  a  muscle;  this  is  more  probably 
due  to  direct  stimulation  of  the  fibers  than  to  excitation  of  the  motor 
nerves.  Myokymia,  a  condition  characterized  by  constant  undulating 
or  wavelike  contractions  of  the  muscle  fiber  which  changes  from 
place  to  place,  has  been  regarded  as  a  symptom  of  abortive  neuritis, 
but  is  rarely  seen. 

After  complete  division  of  a  nerve  and  primary  suture  the  time 
necessary  for  the  return  of  power  depends  on  the  distance  of  the 
lesion  from  the  periphery ;  Sherren  lays  down  the  rule  for  the  upper 
extremities,  that  when  a  nerve  is  divided  at  the  wrist  perfect  power 
may  be  regained  within  a  year;  but  if  at  the  elbow  or  in  the  plexus 
not  for  two  years.  The  muscles  nearer  the  lesion  regain  their  func- 
tions earlier  than  those  distant  from  it.  Eecovery  is  slower  after 
secondary  than  after  primary  suture.  The  muscular  functions  return 
much  more  rapidly  after  incomplete  nerve  l.esions. 

Sensory  symptoms. — Wlien  a  sensory  nerve  or  the  sensory  fibers  of  a 
mixed  nerve  are  cut  across  we  might  expect  to  find  absence  of  all 
sensation  in  the  cutaneous  and  deep  structure  which  are  supplied  by 
that  nerve;  but  by  the  ordinary  methods  of  testing  this  is  rarely 
found,  as  the  sensory  loss  which  is  revealed  is  generally  much  less  ex- 
tensive than  the  anatomical  distribution  of  the  nerve.  This  has  been 
generally  explained  by  assuming  that  the  nerves  overlap  or  anasto- 
mose, or  that  the  neighboring  end  organs  take  up  sensibility  from  the 
anesthetic  region.  But  the  explanation  has  been  afforded  by  the 
brilliant  work  of  Head  and  his  colleagues.  These  have  shown  that 
the  afferent  fibers  may  be  divided  into  three  systems.  The  first  sys- 
tem subserves  deep  sensibility,  which  is  conveyed,  as  Sherrington  has 
shown,  by  the  afferent  fibers  that  run  from  the  muscles,  tendons,  and 
joints,  and  which  escape  when  only  cutaneous  sensory  nerves  are  in- 
jured. Even  when  the  muscular  branches  are  involved  this  form  of 
sensibility  may  not  be  quite  abolished,  as  its  fibers  have  wide  anasto- 
moses and  often  join  the  tendons  and  muscles  high  up  in  the  limbs. 
Its  function  is  the  appreciation  of  pressure,  of  stimuli  that  produce 
deformation  of  structure,  and  of  any  change  in  the  position  and 
condition  of  the  joints  and  muscles.  It  is  the  system  which  subserves 
the  sense  of  position.  It  is  owing  to  the  persistence  of  deep  sensi- 
bility that  the  statement  is  often  made  that  no  sensory  loss  ensues  on 
the  section  of  a  cutaneous  nerve,  as  the  area  of  its  distribution  re- 
mains sensitive  to  even  light  pressure  by  a  finger  or  pencil  point. 

The  second  system,  to  which  the  name  protopathis  is  given,  con- 
veys painful  cutaneous  stimuli  and  the  appreciation  of  the  major 
degrees  of  temperature.    But  in  the  absence  of  the  third  system  the 

13764—17 20 


306  WAR   SUEGERY    OF    THE    NERVOUS    SYSTEM. 

pain  produced  by  a  pin  prick  or  other  means  is  not  localized,  but 
radiates  widely  over  the  affected  area  and  causes  an  unnatural  amount 
of  discomfort  and  an  almost  uncontrollable  desire  to  withdraw  the 
part  from  the  stimulus.  Although  it  is  through  this  system  that 
major  degrees  of  heat  and  cold  are  appreciated,  minor  degrees  of 
temperature  can  not  be  recognized  wheii  it  is  alone  present,  and  the 
appreciation  of  degrees  of  heat  and  cold  is  lost.  The  third  system, 
which  has  been  called  epicritic,  responds  to  light  touches  and  to  the 
minor  degrees  of  temperature,  which  produce  the  sensations  called 
"  warm  "  and  "  cool."  It  is  only  when  epicritic  sensibility  is  present 
that  the  point  of  skin  touched  can  be  accurately  localized  and  that 
two  points  at  a  normal  distance  apart  can  be  discriminated  when 
applied  simultaneously. 

In  the  sensory  disturbances  that  result  from  section  of  a  peripheral 
nerve  the  different  varieties  of  sensibility  are  lost  according  to  their 
arrangement  in  these  three  systems ;  that  is,  sensibility  to  light  touch 
and  the  minor  degrees  of  temperature  disappear  together,  and  the 
appreciation  of  the  major  degrees  of  temperature  with  insensibility  to 
painful  cutaneous  stimuli. 

When  the  condition  of  sensation  on  the  hand  is  examined  after 
section  of  the  ulnar  nerve  it  will  be  seen  that  there  is  complete  loss 
of  all  forms  of  sensation  only  on  the  little  finger  and  on  a  variable, 
but  small,  area  on  the  ulnar  border  of  the  hand ;  that  is,  it  is  only  here 
that  both  the  protophathic  and  epicritic  sensibilities  are  absent,  but 
on  the  rest  of  the  cutaneous  distribution  of  the  ulnar  nerve  light 
touch  and  the  intermediate  degrees  of  temperature,  the  epicritic 
sensibilities  can  not  be  appreciated,  and  although  painful  stimuli  may 
be  recognized  they  can  not  be  accurately  localized,  but  radiate  widely 
and  give  rise  to  unnatural  discomfort.  It  is  evident  that  though  there 
may  be  a  considerable  overlap  between  the  fibers  of  the  ulnar  and 
median  nerves  which  conduct  protopathic  sensibility,  the  loss  of 
epicritic  is  practically  limited  by  the  anatomical  boundary  of  the 
nerve  distribution.  With  other  nerves  there  may  be  an  overlapping 
of  epicritic  sensation  too.  When  the  fibers  are  injured  in  a  plexus 
the  area  of  loss  of  protopathic  sensibility  may  almost  equal  in  extent 
that  of  the  epicritic,  while  if  due  to  lesion  of  the  dorsal  spinal  roots, 
the  area  insensitive  to  a  pin  prick  may  actually  exceed  that  insensi- 
tive to  light  touch.  The  more  closely  a  peripheral  nerve  represents 
the  supply  of  one  or  more  posterior  roots  the  more  nearly  will  the  loss 
of  protopathic  coincide  in  distribution  with  the  loss  of  epicrictic 
sensibility.  Head's  conclusions  have  been  contested  by  Trotter  and 
Davies  and  others. 

When  a  nerve  is  not  completely  divided,  or  if  only  its  functional 
continuity  is  affected,  as  by  bruising  or  compression,  the  condition  of 
sensation  is  very  variable.     Sometimes  every  form  of  sensibility  is 


DISEASES  OF   PERIPHEBAL   NERVES.  307 

lost  for  a  time,  but  often  pain  perception  remains  intact  and  loss  of 
epicritic  sensibility  may  be  the  only  sign  of  the  injury,  or  after  slight 
injuries  there  may  be  no  absolute  loss  of  sensation,  though  the  patient 
may  be  conscious  of  an  altered  sensibility  in  the  area  of  the  nerve. 

The  recovery  of  sensibility  in  the  area  of  a  divided  nerve  which  has 
been  sutured  and  is  regenerating  takes  place  in  a  definite  and  con- 
stant manner.  The  first  change,  generally  observed  after  about  two 
to  three  months,  is  a  gradual  diminution  of  the  area  of  total  analgesia 
commencing  in  the  proximal  parts  of  the  area,  and  recovery  of  ap- 
preciation of  major  degrees  of  temperature,  Avhile  the  area  of  in- 
sensibility to  light  touch  remains  unaltered.  At  this  stage,  generally 
completed  in  about  six  months,  there  is  still  absolute  loss  of  epicritic 
sensibility,  although  all  the  forms  of  protopathic  sensation  have  re- 
covered. The  diffuseness  and  radiation  of  pain  produced  by  a  pin 
prick,  or  roughly  handling,  or  a  blow  is  so  unpleasant  at  this  stage 
that  the  complete  absence  of  sensation  may  appear  preferable  to  the 
patient.  The  return  of  sensibility  to  light  touch  and  the  minor  de- 
grees of  temperature,  as  well  as  the  power  of  discriminating  between 
one  and  two  points  and  of  accurately  localizing  stimuli,  rarely  com- 
mences earlier  than  six  months,  no  matter  how  favorable  the  nerve 
union  may  be,  and  is  seldom  complete  within  a  year ;  but  even  for  years 
careful  examination  may  detect  abnormalities. 

After  incomplete  nerve  lesions,  on  the  other  hand,  the  appreciation 
of  pain  and  of  light  touch  return  at  approximately  the  same  time; 
it  may  be  taken  as  an  absolute  rule  that  if  the  simultaneous  recovery 
of  protopathic  and  epicritic  sensibility  is  observed  within  a  few 
months  of  the  injury  the  nerve  has  not  been  completely  divided. 
Recovery  of  function  is  also  much  more  rapid  than  after  complete 
division  of  the  nerve.  It  commences  at  a  date  which  varies  with  the 
distance  of  the  injury  from  the  periphery,  from  about  three  weeks 
at  the  wrist  to  six  months  in  the  plexus  and  also  with  its  degree. 

Symptoms  of  irritation  or  perversion  of  function  of  sensory  fibers 
are  often  a  prominent  feature  of  disease  or  injury  of  the  peripheral 
nerves,  especially  when  the  lesion  is  only  partial  or  when  the  central 
stump  of  a  divided  nerve  is  involved  in  scar  tissue.  Pain  is  the  most 
important  of  these  subjective  symptoms.  Irritation  of  a  nerve  by 
pressure  or  disease  may  give  rise  to  severe  pain ;  this  is  undoubtedly 
due  to  the  excitation  of  the  sensory  fibers  by  the  lesion ;  the  abnormal 
excitation  thus  produced  is  conveyed  by  the  ordinary  paths  to  the 
higher  sensory  centers  of  the  cerebral  cortex,  where  it  reaches  con- 
sciousness; its  origin  is,  however,  misinterpreted  and  is  referred  to 
the  sensory  end  organs  of  the  irritated  fibers,  even  although  the  area 
in  which  they  lie  be  completely  anesthetic — anesthesia  dolorosa.  Pain 
of  this  origin  is  often  paroxysmal  and  is  generally  sharp,  burning,  or 


308  WAE   SURGERY    OF   THE    NERVOUS   SYSTEM. 

darting ;  at  times,  however,  it  is  of  a  dull  aching  or  boring  character ; 
it  may  be  referred  to  the  skin  or  the  deeper  structures  of  the  limbs. 

Hyperalgesia  is  met  with  in  regions  in  which  epicritic  sensation  is 
lost,  whole  protopathic  persists,  but  it  often  follows  partial  lesions 
where  there  is  little  or  no  disturbance  of  sensation.  It  not  infre- 
quently extends  over  the  boundary  of  the  anatomical  distribution  of 
the  injured  nerve  and  is  often  associated  with  severe  spontaneous  pain. 

Weir  Mitchell  gave  the  name  causalgia  to  a  condition  of  severe 
spontaneous  pain  associated  with  hyperalgesia  and  tenderness  and 
often  with  trophic  disturbances.  It  is  most  frequently  seen  after 
bullet  wounds ;  it  never  results  from  complete  interruption  of  the  con- 
tinuity of  the  nerve  and  always  disappears  immediately  the  nerve  is 
cut  across  for  secondary  suture.  In  these  cases  it  is  probable  that 
normal  stimuli  of  peripheral  origin  are  augmented  in  their  passage 
through  the  injured  region,  or  it  may  be  that  the  sensory  end  organs 
become  hyperexcitable  owing  to  a  disturbance  of  their  connection  with 
their  trophic  centers.  Hyperalgesia  appears  rarely  if  ever  immedi- 
ately after  the  nerve  injury,  generally  not  for  a  period  of  a  few  weeks. 

Pain  is  uncommon  after  nerve  injuries  by  modern  high- velocity 
bullets;  Olconomakes  saw  it  very  rarely  accompanying  peripheral 
palsies  in  the  Balkan  wars. 

Various  paresthesias,  or  a  feeling  of  loss  of  feeling,  or  of  weight 
or  pressure,  or,  it  may  be,  a  sense  of  warmth  or  coldness,  are  fre- 
quently due  to  affection  of  the  peripheral  ner^-es  which  supply  the 
region  to  which  they  are  referred ;  they  are  generally,  but  not  always, 
associated  with  some  loss  of  sensibility.  They  are,  on  the  whole,  met 
with  more  frequently  in  the  toxic  degenerations  of  nerves  than  after 
traumatic  or  local  lesions;  they  are  probably  due  to  a  slight  but 
persistent  irritation  of  the  sensory  fibers.  The  most  frequent  form 
is  generally  described  as  a  numbness  or  deadness  of  the  part,  but 
from  the  discomfort  it  causes  it  is  evident  that  it  is  more  than  the 
consciousness  of  loss  of  feeling;  it  is  rather  an  abnormal  positive 
symptom,  which  may,  even  when  there  is  no  objective  sensory  dis- 
turbance, seriously  interfere  with  the  functions  of  the  part.  Even 
when  paresthesias  are  due  to  the  local  injury  of  a  nerve,  they  are 
rarely  referred  to  the  whole  area  of  its  anatomical  distribution :  in  the 
limbs  they  tend  to  be  more  intense  peripheral  ward. 

Occasionally  the  irritation  of  one  of  the  terminal  branches  of  a 
nerve  gives  rise  to  pain  extending  over  its  whole  protopathic  dis- 
tribution, or  that  of  its  roots,  which  may  be  accompanied  by  hyperal- 
gesia, or  by  spasm  or  contractures  of  the  muscles  supplied  by  it. 
Neurotomy  of  the  irritated  branch  gives  instant  relief. 

Trophic  and  vasomotor  symptoms. — The  nutrition  and  conservation 
of  all  tissues  of  the  body  are  to  a  certain  extent  dependent  on  the  in- 
tegrity of  their  connection  with  the  central  or  autonomic  nervous 


DISEASES  OF   PEBIPHEEAL   NERVES.  309 

systems,  aiul  when  this  is  intei'ni])te(l  the  isolated  tissues  may  undergo 
certain  changes.  The  most  prominent  of  these  is  the  atrophy  of  the 
muscles  which  follows  the  degeneration  of  the  motor  nerve  fibers 
which  innervate  them,  but  the  skin,  subcutaneous  tissues,  and  even 
bone  may  also  undergo  structural  alterations. 

It  was  for  long  discussed  whether  the  influence  of  the  nervous  sys- 
tem on  the  tissues  is  exerted  through  special  trophic  fibeis,  or  through 
the  ordinary  motor,  sensory,  or  vasomotor  nerves.  The  muscles  are 
certainly  dependent  only  on  the  integrity  of  their  motor  fibei-s,  and 
the  existence  of  special  trophic  fibers  to  other  tissues  has  not  been 
proved.  The  vasomotor  nerves  must,  however,  have  a  considerable 
influence  on  nutrition  and  growth ;  paretic  vasodilatation  follows  sec- 
tion or  injury  of  a  nerve,  and  although  there  maj^  be  hyperemia  and 
a  slight  elevation  of  the  local  temperature  for  a  time,  the  part  soon 
becomes  cold,  congested,  and  even  cyanosed,  owing  to  the  slow  cir- 
culation through  the  dilated  vessels;  and  its  inactivit}^  leads  to  lymph 
stasis. 

It  seems  probable  that  the  trophic  centers  for  the  skin  and  other 
tissues  lie  in  the  spinal  ganglia,  and  that  the  centrifugal  conduction 
of  trophic  influence  is  a  function  of  the  sensory  fibers;  or  more 
probably  that  the  normal  nutritional  equilibrium  is  in  some  way  de- 
termined by  the  sensory  nerves.  The  strongest  evidence  of  the 
trophic  function  of  the  spinal  ganglia  is  that  the  acute  changes  in 
the  skin  which  characterize  herpes  zoster  are  directly  due  to  disease 
of  them.  The  innervation  of  the  blood  vessels  and  of  the  sweat  and 
sebaceous  glands  takes  place  through  the  sympathetic  system ;  in  the 
limbs,  at  least,  these  sympathetic  fibers  are  intimately  associated  with 
those  of  motion  and  sensation. 

Trophic  changes  in  the  skin  vary  with  the  rate  of  evolution  and 
the  degree  of  the  nerve  lesion;  the  more  acute  it  is  the  more  likely 
are  trophic  changes  to  be  prominent.  They  may  be  met  with  either 
in  areas  of  total  anesthesia  or  associated  with  only  partial  disturbance 
of  sensation.  In  areas  of  total  analgesia  the  skin  becomes  thin  and 
atrophic,  and  especially  in  the  hands  and  feet,  inelastic  and  tightly 
stretched  over  the  part;  owing  to  the  cessation  of  sweat  and  sebaceous 
secretion  it  is  usually  very  dry  and  may  be  either  glossy  and  shiny 
or  scaly  when  desquamation  of  the  superficial  layers  of  the  epidermis 
is  delayed.  In  this  condition  it  is  very  liable  to  injury,  and  ulcers 
often  develop,  which,  as  a  rule,  first  appear  as  blisters  or  bullae  ;• 
these  often  appear  to  be  the  result  of  the  trophic  disturbance  alone, 
as  they  may  occur  apart  from  any  assignable  local  cause  or  follow  a 
slight  bruise.  Owing  to  the  loss  of  sensation  the  skin  is  liable  to 
suffer  from  neglect  or  unobserved  injuries,  and  to  this  many  of  the 
trophic  changes  has  been  attributed.     Head  has  observed  tliat  these 


310  WAH  SURGERY   OF   THE    NERVOUS   SYSTEM. 

affections  are  generally  coextensive  with  the  area  of  complete  anal- 
gesia and  disappear  with  the  return  of  protopathic  sensibility. 

Another  form  of  cutaneous  trophic  disturbance  which  follows  in- 
complete lesions  of  nerves  and  is  always  associated  with  spontaneous 
pain  and  hyperalgesia  (causalgia)  was  first  accurately  described  by 
Paget  and  Weir  Mitchell,  and  by  the  former  termed  "  glossy  skin." 
It  is  seen  chiefly  on  the  fingers  and  hands ;  the  skin  becomes  "  smooth, 
hairless,  almost  devoid  of  wrinkles,  glossy  pink  or  ruddy,  or  blotched 
as  if  with  permanent  chilblains"  (Paget).  The  subcuticular  tissues 
shrink,  and  the  skin,  which  appears  tightly  drawn  over  them,  is 
often  cracked  and  the  epithelium  is  partially  lost,  so  that  the  cutis  is 
exposed  in  places.  According  to  Weir  Mitchell  this  condition  is 
often  attended  with  vesicles. 

Changes  in  the  growth  and  condition  of  the  n^ils  often  follow 
nerve  injuries.  Retardation  of  growth  has  been  frequently  described, 
but  Head  has  shown  that  this  is  independent  of  sensory  disturbance 
and  that  want  of  movement  owing  to  paralysis  or  the  fixation  of  the 
limb  is  the  main  factor.  Weir  Mitchell  observed  remarkable  altera- 
tion in  the  nails  associated  with  glossy  skin,  which  consisted  of 
curving  on  their  long  axes,  extreme  lateral  arching,  and  sometimes 
a  thickening  of  the  cutis  beneath  their  extremities. 

When  several  nerves  of  a  limb  are  damaged  the  bones  are  liable 
to  become  fragile^  and  if  it  occurs  in  early  life  their  growth  may  be 
retarded.  Acute  and  extensive  nerve  lesions  may  lead  to  SAvelling 
of  and  effusions  into  joints  in  the  paralyzed  region.  Another  form 
of  chronic  joint  change  occurs  chiefly  in  the  fingers  and  wrists;  it 
commences  with  pain  and  periarticular  thickening  and  may  ulti- 
mately produce  ankylosis. 

The  treatment  of  local  nerve  lesions. — This  naturally  depends  on  the 
nature  and  the  degree  of  the  lesion,  but  there  are  certain  general  lines 
which  should  be  invariably  followed.  In  every  case  the  chief  aims 
should  he  to  maintain  the  nutrition  of  the  parts^  to  keej?  the  faralyzed 
muscles  relaxed^  and  to  prevent  the  occurrence  of  contracture. 

If  the  nerve  has  been  completely  divided,  its  two  ends  should  be 
sutured  together  at  once.  The  prognosis  wdien  primary  suture  is 
possible  is  good,  but  it  depends  to  a  certain  extent  on  the  nerve  in- 
jured, the  nature  of  the  lesion,  the  condition  of  the  wound,  and  the 
distance  of  the  injury  from  the  periphery;  the  muscular  functions 
generally  return  w^ithin  nine  months,  but  sensation  is  rarely  perfect 
for  two  or  three  years.  Often,  however,  the  nerve  injury  is  not 
observed,  or  the  patient  does  not  come  under  treatment  until  after 
a  considerable  time ;  then  secondary  suture  must  be  performed.  The 
outlook  in  these  cases  is  not  so  favorable  as  after  immediate  suture, 
but  the  time  after  the  injury  at  which  the  operation  is  undertaken, 


DISEASES  01^   PERIPHERAL   NERVES.  311 

certainly  up  to  three  years,  seems  to  have  little  influence  on  the  re- 
covery  ( Sherren ) . 

Much  depends  on  the  condition  of  the  muscles;  when  these  have 
entirely  lost  their  galvanic  irritability,  complete  recovery  is  prob- 
ably impossible;  and  according  to  Warrington  and  Jones,  when  the 
paralysis  has  lasted  several  weeks,  return  of  full  power  can  not  be 
expected  unless  paralyzed  muscles  have  been  kept  relaxed.  It  is 
important  that  not  merely  should  all  scar  tissue  around  the  ends  of 
the  nerves  be  removed,  but  that  these  should  be  freshened  up  and 
brought  into  accurate  apposition.  It  is  occasionally  impossible  to 
bring  the  divided  ends  together ;  then  Assaky  recommended  imposing 
catgut  threads  between  them  to  form  a  scaffold  along  which  the  re- 
generating axis  cylinders  may  grow,  and  Vanlair  has  introduced 
the  method  of  interposing  a  tube  of  decalcified  bone  or  a  piece  of  a 
small  artery  or  vein  for  the  same  purpose.  Nerve  transplantation, 
however,  seems  to  give  more  favorable  results  in  such  cases,  but,  as 
Merzbacher  has  shown,  the  portion  of  nerve  inserted  can  take  an 
active  part  in  regeneration  only  when  it  is  taken  from  the  same 
animal  or  an  animal  of  the  same  species;  if  taken  from  another 
species  it  immediately  necroses  and  can  consequently  at  the  most  act 
only  as  a  scaffold.  In  other  cases  it  is  preferable  to  anastomose  .the 
peripheral  end  of  the  i)aralyzed  nerve  into  a  neighboring  healthy 
trunk,  or  end  to  end  with  a  flap  raised  from  the  sound  nerve.  In 
every  case  the  exact  condition  of  the  injured  nerve  should  be  ex- 
■imined  under  an  anesthetic  if  there  is  complete  reaction  of  degenera- 
tion in  the  muscles  it  Supplies  after  14  days. 

Tendon  transplantation  is  occasionally  necessary,  especially  when 
there  is  such  complete  degeneration  of  the  paralyzed  muscles  that 
recovery  after  secondary  suture  of  the  nerve  can  not  be  expected. 
The  results  obtained  are  often  favorable.  It  is  interesting  that  after 
nerve  anastomosis  and  tendon  transplantation  nerve  centers  in  the 
cord  can  acquire  new  functions  or  adapt  themselves  to  new  conditions. 

Whatever  surgical  treatment  is  adopted,  it  is  important  to  keep  the 
paralyzed  muscles  relaxed  and  prevent  shortening  and  contracture 
of  their  antagonists.  If  the  extensors  of  the  wrist  and  fingers  are 
paralyzed,  their  joints  must  be  kept  fully  extended  by  a  splint  along 
the  forearm  and  hand ;  if  it  is  the  flexors  of  the  forearm,  the  elbow 
should  be  held  flexed  in  a  sling.  But  the  splint  or  other  apparatus 
used  should  be  removed  frequently  and  massage  and  passive  move- 
ments carried  out. 

The  next  aim  should  be  to  maintain  the  paralyzed  muscles  in  as 
good  a  state  of  nutrition  as  is  possible,  and  for  this  electrical  treat- 
ment is  usually  employed.  If  the  paralysis  is  not  complete,  and  if 
some  excitability  to  the  interrupted  current  remains,  faradism  may 


312  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

be  employed,  but  it  is  of  little  use  if  the  muscles  will  not  react  to  it, 
although,  according  to  Mann,  regular  treatment  raises  the  excit- 
ability of  both  nerve  and  muscle  and  increases  the  flow  of  blood  and 
lymph.  Galvanism  is  more  effective  when  the  muscles  will  not  react 
to  faradism,  but  the  current  employed  should  not  be  too  strong. 

Systematic  and  energetic  massage  is  probably  more  effective  than 
any  form  of  electrical  treatment  and  should  be  combined  with  it, 
but  the  region  of  the  nerve  injury  should  not  be  forcibly  handled. 
Passive  movements  are  always  advisable,  and  the  patient  should 
make  efforts  to  use  the  paralyzed  muscles  as  soon  as  any  return  of 
power  sets  in. 

SPINAL  NERVES. 

The  cervical  plexus. — Owing  to  its  deep  position  among  the  mus- 
cles of  the  neck  the  cervical  plexus  is  rarely  injured  or  affected  by 
disease.  The  branch  which  is  of  most  clinical  importance  is  the 
phrenic  nerve.  Its  paralysis  may  be  due  to  a  lesion  in  the  ventral 
horns  of  the  cord  at  the  level  of  its  origin,  to  an  intraspinal  hemor- 
rhage or  tumor,  or  to  syringomyelia.  Duchenne  first  described  it 
in  progressive  muscular  atrophy.  It  is  most  frequently  caused  by 
involvement  of  the  third  and  fourth  cervical  roots  in  meningeal  or 
cerebral  disease,  especially  in  spinal  caries  and  syphilitic  pachy- 
meningitis. Owing  to  its  deep  position  the  nerve  trunk  is  relatively 
immune  from  trauma,  but  it  is  occasionally  injured  by  wounds  or 
operations.  It  has  been  repeatedly  observed  after  local  anesthesia 
of  the  brachial  plexus.  Within  the  thorax  it  may  be  compressed  by 
tumors,  aneurisms,  or  enlarged  glands.  Unilateral  paralysis  can 
be  often  attributed  only  to  a  local  neuritis,  perhaps  following  ex- 
posure to  cold.  Bilateral  palsy  sometimes  occurs  in  multiple  neu- 
ritis, especially  in  that  form  which  follows  the  acute  infective  dis- 
ease, in  lead  poisoning,  and  in  tabes  dorsalis  (Gerhardt). 

The  diaphragm  is  one  of  the  most  important  of  the  respiratory 
muscles;  when  the  patient  is  at  rest  its  inactivity  may  give  no 
trouble,  but  dyspnea  is  easily  produced  by  exertion  or  when  respira- 
tion is  interfered  with  by  disease  of  the  lungs  or  pleura.  If  bilateral 
paralysis  sets  in  suddenly  there  may  be  considerable  dyspnea  and 
even  cyanosis  for  a  time,  but  it  is  quickly  relieved  by  the  activity 
of  the  accessory  muscles.  Several  cases  have  been  recorded  in  which 
accidental  injury  of  one  phrenic  nerve  during  operation  in  the  neck 
has  led  to  a  fatal  result,  but  Schroeder  and  Green,  who  analyzed 
these  cases,  came  to  the  conclusion  that  death  was  generally  due  to 
some  other  cause. 

When  there  is  complete  bilateral  paralysis  the  upper  part  of  the 
abdomen  is  no  longer  protruded  with  each  inspiration,  but  sinks  in 
as  the  diaphragm  is  drawn  upward  by  the  negative  pressure  in  the 


DISEASES  OF   PERIPHEEAL   NERVES.  313 

thorax;  on  pi'lpation  tlio  descent  of  the  liver  and  spleen  can  be  no 
longer  felt,  and  the  patient  is  unable  to  expand  the  abdomen  by- 
taking  a  deep  breath.  The  inovenients  of  the  thorax  are  conse- 
quently often  increased,  and  the  excessive  movement  of  the  lower 
part  of  the  thoracic  cage  may  draw  the  abdominal  wall  tense;  this 
must  not  be  mistaken  for  the  effect  of  the  descent  of  the  diaphragm. 
If  the  paralysis  is  not  complete,  the  protrusion  of  the  abdomen  in 
inspiration  can  be  easily  resisted  by  pressure.  Owing  to  inability 
to  take  a  deep  breath  there  is  difficulty  in  coughing,  and  the  patient 
can  not  spit  out  with  the  normal  force  nor  sneeze  properly,  and 
there  may  be  difficulty  in  defecation.  Pulmonary  symptoms  are 
the  most  important  complication;  owing  to  the  relative  immobility 
of  the  bases  of  the  lungs  they  may  have  become  dangerously  con- 
gested. 

I'he  symptoms  of  unilateral  paralysis  are  generally  slight  and 
frequently  escape  observation,  but  the  deficient  movement  of  on?, 
side  can  be  definitely  determined  by  a  radiograph  or  by  the  direct 
observation  of  the  movements.  The  electrical  excitability  of  the 
phrenic  nerves  may  be  examined;  they  are  easily  stimulated  in  the 
neck  between  the  sternomastoid  and  scalenus  anticus  muscles  and 
above  the  omohyoid.  The  phrenic  nerves  also  convey  sensory  fibers 
to  the  pleura,  pericardium,  and  diaphragm,  but  sensory  symptoms 
have  been  rarely  referred  to  their  disease:  in  a  few  cases.  hoAvever, 
patients  have  complained  of  pain  in  the  mediai-tinum  and  in  the 
region  of  the  diaphragm. 

The  diagnosis  of  diaphragmatic  paralysis  is  not  always  easy; 
the  examination  of  the  electrical  excitability  of  the  phrenic  nerves 
may  be  very  important  when  other  signs  are  not  conclusive.  In 
the  majority  of  the  cases  the  condition  is  only  part  of  a  general 
peripheral  neuritis,  or  of  poliomyelitis.  Otherwise,  bilateral  paraly- 
sis is  generally  due  to  some  disease  in  the  spinal  cord  or  meninges; 
it  can  then  be  rarely  an  isolated  symptom.  The  vertebral  column 
should  be  carefully  examined  and  the  existence  of  tumors  in  the 
neck  and  mediastinum  excluded.  Paralysis  must  be  distinguished 
from  immobility  of  the  diaphragm  owing  to  diaphragmatic  pleurisy 
or  peritonitis,  or  to  large  pleural  effusions.  Or  the  diaphragm 
may  be  weak  owing  to  secondary  degenerative  changes.  Acute 
fatty  degeneration  of  its  muscle  fibers  frequently  occurs  in  diph- 
theria, and  may  enfeeble,  but  rarely  paralyzes  the  action  of  the 
muscle. 

Treatment. — This  should  be  directed  to  the  removal  of  the  cause  if 
it  is  possiljle,  but  it  is  rarely  so  unless  it  is  due  to  an  operable  tumor 
either  in  the  vertebral  canal  or  neck.  Otherwise  the  chief  aim  should 
be  to  aA'oid  all  pulmonary  complications  and  save  the  patient  from 
exertion.      If   there   is    reason    to    suspect    a    local    neuritis,    warm 


314  WAR   SUEGEEY   OF    THE    NEEVOUS   SYSTEM. 

fomentations  and  counterirritation  may  be  applied  over  the  lower 
part  of  the  anterior  triangle  of  the  neck.  Electricity,  especially  the 
faraclic  current,  has  been  employed  with  apparently  some  effect; 
the  one  electrode  should  be  placed  over  the  phrenic  nerve  immedi- 
ately behind  the  sternomastoid  muscles  in  the  neck,  the  other  over 
the  epigastrium. 

Long  thoracic  nerve. — Isolated  paralysis  of  this  nerve  is  rare.  Stein- 
hausen  was  able  to  collect  records  of  only  29  pure  cases.  It  is  more 
frequently  found  in  association  with  palsy  of  other  muscles  of  the 
shoulder  girdle,  and  it  is  often  seen  in  progressive  muscular  atrophy 
and  in  the  muscular  dystrophies.  The  nerve  may  be  injured  in  the 
neck  by  blows  or  perforating  wounds,  or  by  direct  pressure  from 
a  heavy  weight  carried  on  the  shoulder,  and  it  occasionally  happens 
that  it  is  bruised  by  the  forcible  contraction  of  the  scalinus  medicus 
muscle  through  which  it  passes,  or  by  excessive  stretching  of  the 
nerve  when  the  arm  is  raised  above  the  head,  as  in  painting  a  ceiling, 
climbing  hand  over  hand,  or  hanging  suspended  by  the  arms.  In 
the  axilla  it  may  be  injured  by  a  perforating  wound  or  by  operation. 
Paralysis  of  the  serratus  magnus  has  also  been  observed  after  in- 
fective disease,  and  with  acute  arthritis  of  the  shoulder  joint.  In 
some  cases  it  has  been  apparently  due  to  a  local  neuritis  following 
exposure  to  cold.  It  is  much  more  frequent  in  strong,  muscular  men 
than  in  women  and  is  more  common  on  the  right  side.  Its  paralysis 
produces  very  little  deformity  while  the  arm  is  at  rest;  the  scapula 
may  stand  slightly  higher  than  normal,  with  its  inferior  angle 
slightly  approximated  to  the  vertebral  column  and  separated  from 
the  chest  wall.  When  the  arm  is  moved  forward  into  the  horizontal 
position  or  pressed  forward  against  resistance,  the  scapula,  no  longer 
held  against  the  thorax  by  the  serratus,  is  rotated  on  its  vertical  axis, 
so  that  its  vertebral  border  projects  backward  and  appears  winged. 
This  deformity  is  almost  pathognomonic  of  serratus  palsy.  There  is 
also  difficulty  in  raising  the  arm  above  the  horizontal,  as  while  the 
arm  is  normally  abducted  from  the  side  as  far  as  the  horizontal 
level  by  the  deltoid  alone,  its  further  elevation  is  brought  about  by 
rotation  of  the  scapula  chiefly  by  the  serratus  magnus.  The  latter 
part  of  the  movement  is  consequently  lost  when  this  muscle  is 
paralyzed,  but  not  invariably,  as  it  can  be  sometimes  carried  out  by 
contraction  of  the  middle  fibers  of  the  trapezius.  There  is  often 
diminished  muscular  power  in  the  whole  arm,  which  disappears 
when  the  scapula  is  firmly  bound  to  the  trunk.  Slight  scoliosis  is 
frequently  observed  in  cases  of  serratus  palsy;  it  is  probably  due  to 
an  attempt  to  reestablish  the  equilibrium  upset  by  the  malposition 
of  the  shoulder.  When  the  paralysis  is  due  to  a  neuritis  its  onset 
is  often  accompanied  by  severe  neuralgic  pains  in  the  supraclavicular 
region,  which  may  radiate  up  the  neck,  behind  the  scapula  and  even 


DISEASES    OF    PERIPHERAL    NERVES.  315 

into  tlic.  arm,  but  no  loss  of  sensation  results  from  an  isolated 
paralysis  of  the  long  thoracic  nerve. 

Treatment.— This  must  be  conducted  on  the  usual  lines;  it  is  im- 
portant to  prohibit  work  or  exercise  which  must  produce  pressure  or 
strain  on  the  nerve.  When  the  palsy  is  incurable,  the  humeral 
attachment  of  a  portion  of  the  pectoralis  major  may  be  inserted  into 
the  serratus  magnus. 

The  suprascapular  nerve. — Isolated  paralysis  of  it  is  very  rare; 
Fischler  was  able  to  collect  only  14  cases.  In  half  of  these  it  was 
due  to  direct  or  indirect  trauma,  in  others  apparently  to  a  local  neu- 
ritis; it  may  be  caused  by  the  pressure  of  a  heayy  weight  carried  on 
the  shoulder  or  b}^  a  fall  of  the  shoulder  or  the  outstretched  arm.  Its 
most  prominent  symptom  is  flattening  of  the  infraspinous  fossa  and 
weakness  of  outward  rotation  of  the  humerus  owing  to  the  atrophy 
and  palsy  of  the  infraspinatus ;  this  movement  is  not,  however,  com- 
pletely absent,  as  the  teres  minor  and  the  posterior  fibers  of  the  del- 
toid can  execute  it,  but  only  very  feebly.  According  to  Duchenne,  the 
chief  function  of  the  supraspinatus  is  to  act  fis  an  elastic  ligament 
in  keeping  the  head  of  the  humerus  in  close  apposition  to  the  glenoid 
cavity ;  when  it  is  paralyzed,  the  humerus  falls  away  and  the  move- 
ments of  the  shoulder  joint  are  impeded,  especially  abduction  and 
elevation  in  the  sagittal  plane.  In  every  case  of  its  paralysis  the 
patient  has  complained  of  weakness  and  fatigue  in  the  shoulder  and 
of  the  inability  to  carry  weights.  No  definite  disturbance  of  sensa- 
tion has  been  detected  with  suprascapular  palsy,  but  its  onset  may  be 
accompanied  by  pain  in  the  shoulder  girdle. 

The  circumflex  nerve. — Paralysis  is  most  often  due  to  such  injury  as 
a  blow  or  fall  on  the  shoulder,  dislocation  of  this  joint,  or  fracture 
of  the  upper  end  of  the  humerus.  Occasionally  it  is  caused  by  the 
pressure  of  a  crutch  or  by  lying  for  long  on  the  shoulder  in  deep 
sleep  or  in  an  unconscious  state;  in  those  cases  in  which  paralysis 
follov/s  prolonged  operations  imder  anesthesia  the  lesion  is  evidently 
due  either  to  compression  or  undue  stretching  of  the  nerve.  Simi- 
larly paralysis  of  the  circumflex  has  been  frequently  observed  in 
miners  who  work  lying  constantly  on  the  left  side.  Local  neuritis 
may  be  due  to  exposure  or  to  extension  of  inflammation  from  arthritis 
or  from  disease  in  the  axilla ;  neuritis  has  also  been  observed  in  infec- 
tious diseases  and  in  diabetes.  It  is  noteworthy  that  Bernhardt  and 
Buzzard  have  observed  isolated  paralysis  of  the  circumflex  nerve  in 
lead  poisoning, 

A  complete  lesion  of  the  nerve  leads  to  complete  paralysis  of  the 
deltoid,  exce]:)t  of  a  small  number  of  its  anterior  fibers,  which  are 
supplied  by  the  anterior  thoracic  nerves.  Abduction  and  elevation 
of  the  arm  in  any  plane  are  consequently  impossible,  except  by  rota- 
tion of  the  scapula  by  the  trapezius  and  serratus  magnus.     The 


316  WAR   SUEGEEY   OF    THE    NEKVOUS   SYSTEM. 

supraspinatus  may  also  aid  in  this  movement.  The  shoulder  joint 
becomes  relaxed,  and  owing  to  the  wasting  of  the  deltoid  its  shape  is 
altered.  The  paralysis  of  the  teres  minor,  which  depresses  the  arm 
and  rotates  its  outward,  is  less  prominent.  The  onset  is  generally 
accompanied  by  much  pain.  Objective  sensory  disturbances  are  not 
constant,  but  in  typical  cases  the  area  of  anesthesia  to  light  touch 
occupies  an  oval  area  on  the  outer  side  of  the  arm  extending  from 
the  level  of  the  acromion  process  rather  more  than  half  way  to  the 
elbow ;  the  loss  of  sensibility  to  pain  and  the  extremes  of  temperature 
is  less  extensive.  When  the  paralysis  lasts  for  long  there  is  danger 
of  adhesions  forming  in  the  shoulder  point,  and  ankylosis  may  occur. 
In  obstinate  cases  good  results  have  been  obtained  by  transplanting 
the  clavicular  portion  of  the  trapezius  and  pectoralis  major  into  the 
deltoid  and  by  grafting  the  subscapular  nerve  into  the  circumflex. 

A  little  care  and  examination  of  the  electrical  reaction  of  tlip 
muscle  serves  to  distinguish  primary  joint  disease  with  the  secondary 
wasting  of  the  muscle  from  circumflex  paralysis. 

The  musculocutaneous  nerve. — It  is  rarely  paralyzed  alone.  Bern- 
hardt collected  only  14  cases,  but  as  it  is  not  infrequently  associated 
with  lesions  of  other  nerves  it  is  important  to  recognize  its  symptoms. 
It  is  generally  due  to  a  blow  on  or  compression  of  the  arm  or  to 
fracture  or  dislocation  of  the  humerus.  When  the  lesion  is  com- 
plete the  biceps  and  coracobrachialis  are  absolutely  paralyzed,  as 
well  as  the  greater  portion  of  the  brachialis  anticus.  Flexion  of  the 
elbow  is  consequently  impossible  when  the  forearm  is  supinated, 
but  it  can  be  carried  out  feebly  and  in  limited  range  by  coiitraction 
of  the  supinator  longus  when  the  forearm  is  pronated.  Sensory 
disturbance  is  limited  to  the  radial  side  of  the  forearm  and  the  thenar 
eminence. 

The  musculospiral  or  radial  nerve. — This  is  probably  paralyzed  more 
frequently  than  any  other  nerve  in  the  arm.  It  may  be  injured  in 
the  axilla  by  dislocation  or  fracture  of  the  upper  end  of  the  humerus, 
or  involved  in  callus  formation  or  by  the  pressure  of  a  crutch.  It  is 
occasionally  compressed  by  the  head  of  the  humerus  when  the  arm 
is  kept  full  abducted  and  extended  during  operations  under  anes- 
thesia (Braun).  But  it  is  much  more  frequently  injured  during  its 
course  round  the  humerus,  very  often  by  the  pressure  to  which  it 
is  exposed  when  a  person  sleeps  on  a  hard  or  uneven  surface  with 
the  arm  beneath  his  body  or  with  the  weight  of  the  head  resting  on 
the  outer  surface  of  the  arm.  This  occurs  so  often  in  a  arunKeti 
sleep  that  it  has  been  assumed  that  chronic  alcoholism  predisposes 
ta  it  by  lowering  the  vitality  of  the  nerve  (Oppenheim).  Gowers 
has  pointed  out  that  it  may  be  injured  as  it  passes  through  the 
triceps  by  a  sudden  violent  contraction  of  this  muscle.    Its  paralysis  ' 


DISEASES   OF    PERIPHERAL   NERVES.  317 

has  followed  (lie  use  of  an  Plsiuarch's  bandage  on  the  am),  and  it 
sometimes  results  from  the  injection  of  ether.  A  local  neuritis  due 
to  cold  is  occasionally  assumed  to  be  the  cause.  When  palsy  develox)S 
during  an  acute  illness  it  is  more  probably  due  to  pressure  as  the 
patient  lies  in  a  semiconscious  or  delirious  state.  The  affection  of 
some  of  its  fibers  is  a  characteristic  feature  of  lead  palsy. 

Symptoms. — These  depend  on  the  site  and  the  severity  of  the  injury. 
When  the  lesion  is  in  the  axilla  all  the  muscles  supplied  by  it  are 
paralyzed  and  the  patient  is  no  longer  able  to  extend  the  elbow  and 
wrist  or  the  fingers  or  thumb  at  their  basal  joints,  or  to  supinate  the 
forearm,  except  by  the  biceps.  If  the  nerve  is  injured,  as  it  is  more 
frequentl}^,  on  the  outer  side  of  the  arm,  the  extensors  of  the  elbow 
and  more  rarely  the  supinator  longus  escape,  but  wrist  drop,  which 
is  the  characteristic  feature  of  the  pals3^  is  present.  The  thumb  can 
not  be  abducted  or  extended,  but  its  other  movements  are  iniact. 
Although  the  flexor  muscles  are  not  affected,  the  hand  grasp  is  con- 
siderably weakened  owing  to  the  mechanical  disadvantage  at  which 
they  work  when  the  wrist  is  not  held  straight  by  the  normal  action 
of  their  antagonists;  with  the  hand  passively  extended,  its  grasp  is 
normal.  As  the  arm  hangs  by  the  side  the  forearm  is  generally 
pronated,  and  becomes  more  fully  so  when  the  hand  grasps  any  ob- 
ject, owing  to  the  unresisted  pronation  action  of  the  flexors.  The 
power  of  supination  with  the  elbow  extended  is  completel}^  lost, 
but  when  it  is  flexed  the  biceps  can  supinate  the  forearm.  If  the 
nerve  is  injured  in  the  forearm,  the  supinators  and  even  the  ex- 
tensors of  the  wrist  may  escape.  Paralysis  of  the  supinator  longus 
produces  slight  weakness  of  flexion  of  the  elbow. 

Sensory  symptoms  are  very  variable;  with  the  onset  there  may 
be  subjective  sensations  of  numbness  and  tingling  in  its  cutaneous 
distribution,  generally  most  pronounced  on  the  radial  border  of  the 
hand.  In  incomplete  lesions,  the  sensory  fibers  are,  according  to 
the  general  rule,  much  less  affected  than  the  motor,  and  even  with 
complete  paralysis  of  the  muscle  there  may  be  no  loss  of  sensibility ; 
when  present  the  anesthesia  is  generally  most  marked  over  the  radial 
branch.  Trophic  changes  are  rarely  prominent.  In  the  pressure 
palsies  there  may  be  little  or  no  atrophy  of  the  paralyzed  muscles. 
Occasionally  a  prominence  develops  on  the  dorsum  of  the  hand, 
which  is  due  either  to  the  swelling  of  the  sheaths  of  the  extensor 
tendons  (Gubler)  or  to  overflexion  of  the  carpus.  There  may  be 
slight  effusion  into  the  carpal  joints,  and  adhesions  may  form  in 
them.  The  electrical  reactions  of  the  nerve  and  the  muscles  it  sup- 
plies are  extremely  important ;  in  the  pressure  palsies  the  nerve  may 
be  inexcitable  from  above  the  lesion,  while  in  the  portion  below  it 
and  in  the  muscles  it  supplies  normal  responses  can  be  obtained ;  the 


318  WAR    SUE.GEEY    OF    THE    NERVOUS    SYSTEM. 

conduction  of  volitional  and  electrical  impulses  is  thus  interrupted 
by  a  lesion  which,  is  not  of  sufficient  intensity  to  damage  the  con- 
tinuity or  vitality  of  the  nerve  fibers.  If  the  lesion  is  more  severe 
there  must  be  partial  or  complete  reaction  of  degeneration  in  the 
muscles  it  supplies. 

Paralysis  of  this  nerve  is  generally  easily  recognized,  but,  as 
Gowers  points  out,  the  fact  that  it  produces  loss  of  extension  of  the 
limb  at  all  its  joints  may  lead  to  error,  as  palsy  limited  to  a  single 
function  suggests  central  disease ;  the  absence  of  sensory  loss  and  of 
change  in  the  electrical  excitability  of  the  muscles  may  increase  the 
risk  of  error.  In  lead  palsy  it  is  the  musculo-spiral  groups  of  mus- 
cles which  are  chiefly  involved,  but  the  affection  is  almost  invariably 
bilateral,  the  onset  is  usually  slow  and  unconnected  with  trauma, 
the  supinator  longus,  as  a  rule,  escapes,  and  the  reaction  of  degenera- 
tion appears  early  in  the  paralyzed  muacles. 

Treatment. — This  must  be  conducted  on  the  usual  lines.  In  the 
pressure  palsies  the  application  of  the  galvanic  current  for  20  to 
30  minutes  at  a  time  is  of  value;  the  cathodal  electrode  should  be 
placed  over  the  seat  of  injurj^,  the  anode  distal  to  it,  and  the  strength 
of  current  slowly  increased  until  the  patient  feels  it  distinctly. 

The  median  nerve. — Owing  to  its  deep  position  among  the  soft 
tissues  of  the  arm  this  nerve  is  much  less  liable  to  injury  than  the 
musculo-spiral.  In  the  axilla  and  arm  it  is  usually  injured  by  frac- 
tures and  dislocations  of  the  humerus  and  occasionally  by  the  pres- 
sure of  a  crutch,  but  the  most  frequent  cause  of  its  paralysis  is  a 
wound  on  the  palmar  surface  of  the  wrist.  Occupation  palsies  fre- 
quently involve  some  or  all  of  the  hand  muscles  supplied  by  the 
median  nerve ;  it  has  been  repeatedly  observed  in  laundresses,  joiners, 
milkmaids,  and  cigarette  makers.  The  exact  nature  of  the  lesion  is 
doubtful ;  often  it  is  undoubtedly  due  to  a  neuritis  set  up  by  pressure, 
but  in  other  cases  the  muscular  palsy  and  atrophy  seem  to  be  the 
direct  result  of  the  stress  of  overwork.  Drummer's  palsy  affects 
chiefly  the  thumb  muscles,  but  seems  to  be  generally  due  to  rupture 
of  the  tendon  of  the  extensor  longus  pollicis  (Heinicke). 

When  the  nerve  is  damaged  above  the  elbow  the  power  of  pronat- 
ing  the  forearm  is  lost,  flexion  of  the  wrist  is  feeble  and  incomplete, 
and,  as  it  can  be  performed  only  by  the  ulnar  flexor,  the  hand  is 
strongly  deviated  to  the  ulnar  side.  Flexion  of  the  interphalangeal 
joints  is  also  lost  except  that  of  the  distal  phalanges  of  the  two  ulnar 
fingers,  which  can  be  still  bent  by  the  unparalyzed  part  of  the  flexor 
profundus.  The  flexion  of  the  fingers  on  the  metacarpus  is  un- 
affected, as  it  is  performed  by  the  interossei.  The  unopposed  extensor 
action  of  the  latter  muscles  at  the  interphalangeal  joints  may  lead  to 
their  hyperextension.  The  thumb  is  kept  extended  and  adducted  by 
the  muscles  which  remain,  and  it  can  not  be  opposed  nor  its  distal 


DISEASES   OF    PERTPHEEAL    NERVES.  319 

phalanx  flexed;  its  metacarpal  bone  comes  to  lie  in  the  same  plane  as 
that  of  the  fingers,  like  the  thumb  in  the  ape.  Owing  to  paralysis  of 
these  movements  of  the  fingers  and  thumb  there  is  considerable  diffi- 
culty in  firmly  grasping  any  object  and  in  employing  the  hand  in 
any  work.  When  the  lesion  affects  the  nerve  in  the  forearm,  after  its 
branches  to  the  pronators  and  flexors  have  been  given  off,  pronation 
and  flexion  of  the  wrist  and  fingers  may  be  intact;  then  it  is  chiefly 
the  thumb  movements  Avhich  are  lost.  Bernhardt  and  Head  have 
pointed  out  that  the  branch  which  supplies  the  muscles  of  the  hand 
may  leave  the  main  stem  of  the  nerve  in  the  lower  part  of  the  fore- 
arm and  thus  escape  injury  when  the  wound  is  at  the  wrist.  When 
the  lesion  of  the  nerve  is  severe,  prominent  atrophy  of  the  muscles 
of  the  thenar  eminence  results,  and  of  the  flexor  surface  of  the  fore- 
arm if  it  is  above  the  elbow.  There  may  be  considerable  paresthesia 
in  the  cutaneous  area  of  the  nerve  in  earlier  stages  of  the  paralysis; 
the  occupation  palsies  and  neuritis  are  generalh^  accompanied  by 
troublesome  pain.  A  complete  lesion  of  the  nerve  may  lead  to  trou- 
blesome trophic  disturbance  of  the  skin  and  nails  in  the  area  where 
protopathic  sensibility  is  lost,  and  to  vasomotor  paresis  and  cessation 
of  sweating  in  the  radial  part  of  the  palm. 

The  ulnar  nerve. — This  may  be  injured  alone  or  with  other  nerves 
in  the  axilla  or  upper  arm  by  dislocation  or  fractures  of  the  hume- 
rus, or  involved  in  callus  formation ;  occasionally  it  suffers  in  crutch 
palsy.  It  is  much  more  frequently  damaged  at  the  elbow  joint  by 
dislocations  or  fractures ;  occasionally  ulnar  paralysis  develops  slowly 
at  long  periods  after  elbow  injuries,  owing  probably  to  the  pressure 
of  fibrous  adhesions  or  excess  of  callus  on  the  nerve,  and  in  a  few 
cases  it  has  been  due  to  traumatic  or  synovial  cysts  in  this  region. 
More  rarely  the  curious  condition  of  dislocation  of  the  ulnar  nerve 
from  its  groove  on  the  posterior  surface  of  the  internal  condyle  is 
met  with ;  it  probably  occurs  only  when  the  internal  condyle  is  badly 
developed.  Paralysis  due  to  direct  pressure  from  without  is  rare;  it 
is  occasionally  due  to  pressure  on  the  elbow  during  sleep,  especially 
in  emaciated  subjects  or  during  infective  illness.  According  to 
Braun,  however,  these  sleep  palsies  are  to  be  attributed  to  pressure 
of  the  head  of  the  humerus  on  the  nerve  in  the  axilla  when  the  arm 
is  abducted  and  extended.  But  undoubtedly  wounds  in  the  wrist, 
which  may  either  injure  this  nerve  alone  or  the  median  nerve  and 
flexor  tendons  as  well,  are  the  most  common  cause  of  ulnar  palsy. 
Primary  neuritis  is  rare;  a  few  cases  of  syphilitic  neuritis  are  de- 
scribed, and  leprosy  has  a  predilection  for  this  nerve. 

When  the  nerve  is  injured  at  or  above  the  elbow  the  power  of 
flexion  of  the  hand  is  very  feeble,  and  when  attempted  the  hand  is 
deviated  radialward  by  the  radial  flexor;  the  wrist  becomes  hyper- 
extended  when  the  fingers  are  straightened  owing  to  the  palsy  of 


320  WAR   SURGERY   OP    THE    ISTERVOUS  SYSTEM. 

its  ulnar  flexor.  The  movements  of  the  little  finger  are  lost,  the 
middle  and  ring  fingers  can  not  be  flexed  at  their  distal  joints,  and 
owing  to  the  paralysis  of  the  interossei  the  basal  phalanges  of  all 
the  fingers  can  not  be  flexed  or  the  middle  or  distal  phalanges  fully 
extended.  Adduction  and  abduction  of  the  fingers  are  also  impos- 
sible. When  the  injury  is  situated  in  the  lower  part  of  the  forearm 
the  fibers  to  the  flexor  profundus  digitorum  escape  and  the  interossei 
and  thumb  muscles  are  alone  paralyzed;  then,  owing  to  the  unop- 
posed contraction  of  the  long  extensors  and  flexors,  the  hand  be- 
comes clawlike  (main  en  griffe),  with  the  first  phalanges  hyper- 
extended  and  the  interphalangeal  joints  flexed.  As  the  first  two 
lumbricales  escape,  the  deformity  is  generally  not  so  pronounced  as 
it  is  in  progressive  muscular  atrophy  (Gowers).  Adduction  of  the 
thumb  is  also  lost.  The  muscular  atrophy  which  follows  severe 
lesions  of  this  nerve  is  very  typical;  the  hypothenar  eminence  dis- 
appears, the  palm  becomes  hollow^,  and  the  interosseal  spaces  sink  in. 
When  the  nerve  is  severely  damaged  there  is  complete  loss  of  sensa- 
tion in  the  little  finger  and  over  a  variable  extent  of  the  ulnar  border 
of  the  hand;  on  the  ring  finger  and  the  rest  of  the  ulnar  cutaneous 
distribution  sensibility  to  light  touch  and  the  intermediate  degrees 
of  temperature  are  alone  affected.  As  the  dorsal  cutaneous  branch 
separates  from  the  nerve  in  the  middle  third  of  the  forearm  it  may 
escape  in  wounds  at  the  wrist.  Dupuytren's  contracture  of  the 
palmar  fascia  has  been  observed  after  neuritis  of  the  ulnar  nerve, 
and  De  Leon  has  described  contractures  of  the  ulnar  portion  of  the 
flexor  profundus  digitorum,  owing  to  which  the  three  ulnar  fingers 
were  bound  down  in  the  maximal  flexion  position. 

The  chief  danger  of  error  in  diagnosis  is  of  confusing  central  and 
peripheral  lesions,  as  the  ulnar  nerve  contains  almost  all  the  root 
fibers  of  the  eighth  cervical  and  first  thoracic  segments  of  the  cord. 

Paralysis  of  the  brachial  plexus. — The  brachial  plexus  is  formed  by 
the  anterior  primar}^  divisions  of  the  lower  four  cervical  and  the 
first  thoracic  roots;  it  contains  all  the  fibers  which  supply  the 
muscles  of  the  slioulder  girdles  and  upper  extremities,  as  well  as  the 
sensory  fibers  to  almost  the  whole  of  the  arm.  By  division  and  sec- 
ondary anastomosis  of  these  roots  the  three  main  cords  of  the  plexus 
are  formed.  The  outer  cord  receives  the  ventral  trunks  of  the  fifth, 
sixth,  and  seventh  cervical  roots;  the  inner  contains  the  ventral 
trunk  of  the  eighth  cervical  as  well  as  the  whole  of  the  first  thoracic 
root,  and  the  posterior  cord  is  made  up  of  the  dorsal  trunk  of  the 
four  lower  cervical  roots.  This  is  the  most  common  form  of  the 
brachial  plexus,  but  it  is  liable  to  variation,  for  the  fibers  concerned 
in  any  single  function  do  not  constantly  leave  the  cord  by  the  same 
roots;  but  although  fibers  may  alter  their  position  relative  to  the 
vertebral  column,  they  always  maintain  their  position  in  relation  to 


DISEASES  OF   PEBIPHERAL   NERVES.  321 

other  fibers  (Herringham).  The  whole  plexus  may  be  shifted  up — 
high  or  prefixed  type — or  downward — low  or  postfixed  type — and 
the  extreme  variations  between  the  high  and  low  form  of  plexus  may 
amount  to  nearly  a  whole  root  (Harris).  Paralysis  may  be  due  to 
injury  or  disease  of  the  nerve  fibers  in  the  roots,  in  the  plexus,  or 
in  the  nerve  trunks  and  branches.  Two  types  of  plexus  paralysis 
merit  special  description. 

Duchenne-Erb  palsy,  or  the  upper-arm  type. — In  this  form  the  deltoid, 
biceps,  brachialis  anticus,  and  supinator  longus  are  generally  para- 
lyzed together,  and  frequently  also  the  supinator  brevis  and  supra 
^iud  inf raspinati ;  more  rarely  other  muscles  of  the  shoulder  girdle 
and  the  radial  extensor  of  the  wrist  and  the  pronator  radii  teres. 
The  lesion  to  which  it  is  due  involves  the  fifth  and  sixth  cervical 
roots  either  before  or  immediately  after  their  union,  or  occasionally 
the  fifth  root  alone ;  when  caused,  as  it  frequently  is,  by  a  blow  or  fall 
on  the  shoulder,  it  has  been  assumed  that  these  roots  were  compressed 
between  the  clavicle  and  the  transverse  processes  of  the  lower  cervical 
vertebra^,  or  the  first  rib,  but  it  seems  more  probable  that  the  lesion 
is  a  rupture  of  some  or  all  of  the  fibers  of  this  portion  of  the  plexus 
owing  to  excessive  stretching  and  tension.  In  many  cases  at  least 
the  root  fibers  themselves  are  ruptured  or  are  torn  out  from  the  spinal 
cord.  This  may  be  due  to  any  cause  which  increases  the  distance 
between  the  shoulder  and  the  head  and  neck.  The  vulnerability  of 
the  two  upper  roots  of  the  plexus  to  this  form  of  trauma  is  explained 
by  the  fact  that  they  bend  downward  immediately  on  their  exit  from 
the  spine,  so  that  the  extravertebral  portion  of  each  root  forms  an 
angle  open  downward  with  the  portion  Avhich  lies  in  the  interverte- 
bral foramen,  while  in  the  loAver  two  roots  this  angle  is  open  upward, 
tind  in  the  seventh  root  there  is  little  or  no  bend. 

In  severe  cases  the  arm  hangs  by  the  side  and  can  not  be  abducted 
because  of  the  paralysis  of  the  deltoid  or  rotated  outward  at  the 
shoulder  if  the  infraspinatus  is  affected.  Flexion  of  the  elbow  is 
impossible,  oAving  to  the  paralysis  of  the  biceps,  brachialis  anticus, 
and  supinator  longus,  or  it  can  be  effected  through  a  small  range  b}^ 
the  pronator  radii  teres  and  the  flexors  of  the  wrists.  Supination 
of  the  forearm  is  always  weakened  by  the  loss  of  power  in  the  biceps, 
and  it  may  be  impossible  if  the  supinator  brevis  is  also  affected. 
Sensory  symptoms  are  absent  in  the  slighter  cases,  but  there  may  be 
l)aresthesia  and  loss  of  sensation  on  the  radial  side  of  the  arm  and 
forearm.  E^en  complete  section  of  the  anterior  primary  division 
(.f  the  fifth,  and  sometimes  of  the  fifth  and  sixth,  roots  may  produce 
no  sensory  loss  (Sherren).  Erb  has  shown  that  all  the  muscles 
l/iualyzed  in  this  type  of  plexus  palsy  may  be  made  to  contract  by 
electrical  stimulation  over  a  point  in  the  neck  3  cm.  lateral  to  the 
18764—17 21 


322  WAR   SUEGEEY   OF    THE   NEEVOUS   SYSTEM. 

sterno-mastoid  and  the  same  distance  above  the  clavicle;  the  loss  of 
excitability  of  the  nerve  trunks  from  this  point  is  an  important  sign 
of  the  upper  arm  type  of  plexus  palsy. 

Klumpke  palsy,  or  the  lower-arm  type. — This  form  of  paralysis,  in 
which  the  eighth  cervical  and  first  dorsal  roots  are  involved,  is  gen- 
erally met  with  only  as  the  residue  of  a  more  extensive  lesion,  but  it 
may  be  due  to  compression  by  a  tumor  in  the  neck  or  a  growth  in 
connection  with  the  lung  or  vertebral  column.  Owing  to  the  deeper 
position  of  these  roots,  they  are  rarely  injured  by  trauma.  The 
palsy  is  characterized  by  an  atrophic  paralysis  of  the  intrinsic 
muscles  of  the  hand  and  generally  of  some  of  the  foi'earm  muscles, 
especially  the  flexors,  with  a  certain  amount  of  loss  of  sensation  on 
the  ulnar  fingers  and  the  ulnar  border  of  the  hand  and  forearm. 
Frequently,  too,  there  are  pupillary  symptoms,  due  to  injury  of  the 
sympathetic  fibers,  which  leave  the  cord  in  the  first  thoracic  root; 
but  as  these  branch  off  from  the  root  immediately  outside  the  inter- 
vertebral foramen,  they  are  affected  only  when  the  inner  portion  of 
the  root  is  damaged.  When  they  are  injured  the  palpebral  fissure 
is  narrowed,  the  pupil  contracted,  and  there  may  be  a  slight  degree  of 
exophthalmos  on  the  same  side  as  the  arm  palsy.  Vasomotor  paresis 
on  the  same  side  of  the  face  occurs  probably  only  when  the  second 
and  third  thoracic  roots  are  injured  (Klumpke).  When  the  small 
hand  muscles  are  alone  paralyzed  the  typical  deformity  of  claw-like 
hand  results;  if  the  flexors  of  the  fingers  and  wrist  are  also  power- 
less, the  wrist  may  be  hyperextended,  owing  to  contracture  of  the 
extensors. 

These  traumatic  plexus  palsies  are  frequently  followed  by  severe 
spontaneous  pain  in  the  arm,  probably  owing  to  the  constriction  of 
the  nerve  fibers  in  scar  tissue,  and  often  by  trophic  disturbances. 

Nerves  of  the  lower  limbs. — These  are  much  less  frequently  involved 
in  injuries  or  affected  by  disease  than  those  of  the  upper  extremities. 

The  anterior  cural  nerve. — Isolated  palsy  of  this  nerve  is  rare,  but 
it  may  be  due  to  compression  by  abdominal  growths  or  by  a  psoas 
abscess,  or  to  injury  by  fractures  of  the  upper  end  of  the  femur  or 
of  the  pelvis,  or  disease  of  these  bones.  Primary  local  neuritis  is 
seldom  seen,  but  occurs  occasionally  in  diabetes.  This  nerve,  either 
alone  or  with  the  obturator,  may  be  injured  during  parturition;  this 
probably  occurs  with  greater  frequency  than  is  recognized,  owing 
the  the  rapidity  with  which  it  recovers  from  slight  compression  and 
to  the  fact  that  its  symptoms  may  not  be  noticed  while  the  patient 
is  confined  to  bed.  Ernst  has  observed  30  cases  in  800  births.  The 
psoas  muscle  is  paralyzed  only  when  the  nerve  is  damaged  in  the 
immediate  neighborhood  of  the  lumbar  plexus;  when  the  lesion  is 
situated  here  the  thigh  can  not  be  flexed  on  the  abdomen,  and  if 
paralysis  is  bilateral  the  trunk  can  not  be  flexed  on  the  thighs  when 


DISEASES   OF    PERIPHERAL    NERVES.  323 

these  are  fixed;  the  patient  is  consequently  unable  to  rise  from  tlie 
supine  position.  When  the  lesion  is  in  the  intra-abdominal  ])ortion 
of  the  nerve  the  iliacus  alone  is  paralyzed,  and  flexion  of  the  hip  is 
only  weak.  The  most  prominent  symptom  is  paralysis  of  the  ex- 
tensors of  the  knee,  and  the  absence  of  the  knee  jerk  in  the  affected 
limb.  Paralysis  of  these  muscles  does  not  make  standing  or  walking 
impossible,  but  contraction  of  its  flexors  must  be  avoided,  as  the 
patient  can  not  resist  flexion  or  actively  straighten  the  joint.  The 
paralysis  of  the  pectineus  and  sartorius  does  not  produce  any  other 
prominent  symptom. 

Its  sensory  branches  arise  in  the  upper  part  of  the  thigh ;  the 
middle  and  internal  cutaneous  are  distributed  to  the  lower  two-thirds 
of  the  front  and  inner  side  of  the  thigh,  the  internal  saphenous  to  the 
front  and  inner  side  of  leg,  and  the  inner  side  of  the  dorsum  of  the 
foot.  Disturbance  of  sensation,  paresthesia,  or  radiating  pains  may 
be  present  over  these  areas  when  the  nerve  is  injured  at  or  above  the 
level  of  the  groin. 

The  diagnosis  is,  as  a  rule,  evident;  the  only  risk  is  of  confusing 
the  marked  atrophy  of  the  quadriceps  extensor  group  on  the  front  of 
the  thigh  which  occasionally  results  from  inflammation  of  the  knee 
joint  with  atrophy  of  these  muscles,  due  to  a  nerve  lesion;  but  in 
the  former,  although  the  electrical  excitability  of  the  muscles  may 
be  diminished,  there  is  no  reaction  of  degeneration.  The  ordinary 
lines  of  treatment  must  be  followed;  good  results  have  been  ob- 
tained by  grafting  the  tendon  of  one  of  the  flexors  of  the  knee  into 
the  tendons  of  the  quadriceps  extensor  when  the  paralysis  is  per- 
manent. 

The  obturator  nerve. — This  is  still  more  rarely  injured  alone.  It 
ini[j  be  injured  during  parturition,  by  intra-abdominal,  or  pelvic 
growths,  or  by  an  obturator  hernia.  When  the  muscles  it  supplies  are 
completely  paralyzed  the  limb  can  not  be  adducted,  and  although 
it  can  be  raised  by  flexion  of  the  hip,  it  can  not  be  thrown  across  its 
fellow  when  the  patient  is  seated  on  a  chair.  Owing  to  paralysis 
of  the  obturator  externus,  outward  rotation  is  enfeebled,  and  in- 
ward rotation  of  the  thigh  is  also  weak,  as  the  adductor  magnus  is 
paralyzed.  Gait  is  not  seriously  interfered  with.  The  disturbance 
of  sensation  is  limited  to  a  small  area  on  the  inner  side  of  the  lower 
half  of  the  thigh. 

Melalgia  paresthetica  is  a  condition  characterized  by  paresthesia 
and  pain,  usually  with  slight  objective  disturbance  of  sensation,  in 
the  region  supplied  by  the  external  cutaneous  nerve  on  the  front  and 
outer  side  of  the  thigh.  It  occurs  chiefly  in  middle-aged  men,  less 
frequently  in  women.  Its  etiology  is  obscure;  in  many  cases  there 
has  been  a  history  of  trauma ;  probably  the  long  course  of  the  nerve 
through  the  fascia  predisposes  to  its  injury.    In  one  case  a  localized 


324  WAR  SUEGEEY   OF    THE    NERVOUS   SYSTEM. 

perineuritis  was  found,  but  in  other  specimens  there  was  no  ab- 
normality. In  about  one-sixth  of  the  cases  reported  the  condition 
was  bilateral.  In  1900  Schlesinger  analyzed  122  recorded  cases,  and 
in  the  same  year  Musser  and  Sailer  added  10  personal  observations 
in  a  valuable  contribution.  The  condition  has  been  associated  with 
flat  foot.  The  symptoms  vary  greatly  in  intensity  but  the  most 
common  comi3laint  is  of  abnormal  sensations,  of  numbness,  coldness, 
or  tingling-  on  the  front  and  outer  surface  of  the  thigh.  In  other 
cases  pain  is  the  chief  symptom;  it  may  be  very  severe,  but  is  usually 
felt  only  after  walking  or  standing ;  it  is  probably  due  to  constric- 
tion of  the  nerve  as  it  passes  through  the  deep  fascia  when  the  latter 
is  tense.  Occasionally  it  persists  even  when  the  patient  is  lying  down. 
In  the  majority  of  the  cases  there  is  a  point  of  tenderness  just  below 
the  anterior  superior  iliac  spine  where  the  nerve  pierces  the  fascia. 
Objective  sensory  disturbances  are  very  variable,  but  often  consider- 
able; occasionally  there  is  hyperesthesia.  The  symptoms  are  very 
intractable ;  rest  may  be  necessary  when  there  is  much  pain  and  mas- 
sage, and  the  faradic  brush  over  the  course  of  the  nerve  niaj  give 
relief.  Eesection  of  the  nerve  has  cured  some  cases,  but  in  others 
the  pain  has  returned  (Bramwell). 

Similar  symptoms  have  been  occasionally  observed  in  the  distri- 
bution of  the  middle  cutaneous  branch  of  the  anterior  crural  nerve, 
but  generally  associated  with  meralgia  paresthetica.  Lasarew,  who 
has  found  the  condition  isolated,  has  given  it  the  name  meralgia 
paresthetica  anterior. 

Gluteal  nerves. — Isolated  paralysis  of  the  superior  gluteal  nerve  is 
uncommon;  the  muscles  it  supplies  are  the  chief  abductors  and  in- 
ward rotators  of  the  thigh,  and  when  they  are  paralyzed  these  move- 
ments are  weak  or  lost.  As  the  posterior  fibers  of  the  glutei  rotate 
the  limb  outward  this  movement  becomes  weak.  The  interior 
gluteal  nerve  is  rarely  paralyzed  alone;  when  this  occurs  the  thigh 
can  not  be  forcibly  extended,  nor  the  trunk  straightened  on  the  thigh 
when  the  loAver  limbs  are  fixed.  Standing  and  walking  on  a  level 
are  not  seriously  interfered  with,  but  the  limb  is  of  little  use  in 
ascending  steps,  and  the  patient  has  difficulty  in  rising  from  the  sit- 
ting position. 

The  sciatic  nerve  supplies  motor  fibers  to  the  hamstrings  and  to 
all  the  muscles  below  the  knee,  as  well  as  the  skin  in  the  outer  side 
of  the  leg  and  the  whole  of  the  foot,  except  a  small  part  of  the  inner 
portion  of  its  dorsum.  Its  main  terminal  branches  are  the  external 
popliteal  or  anterior  tibial  nerve;  these  generally  separate  in  the 
popliteal  space,  but  are  sometimes  distinct  from  tlieir  origin  in  the 
plexus. 

The  external  popliteal  nerve  may  be  injured  by  direct  trauma  in  an}'' 
part  of  its  course,  but  it  is  especially  liable  to  be  bruised  by  a  blow 


DISEASES   OF   PEKIPHERAL   NERVES.  325 

or  by  pressure  as  it  bends  round  the  fibula.  It  lias  been  occasionally 
torn  or  ruptured  by  violent  extension  of  the  limb,  and  paralysis  has 
been  frequently  observed  in  laborers  who  work  in  a  kneeling  or 
crouching  position;  there  it  is  probably  due  to  compi-ossion  of  the 
nerve  between  the  fibula  and  the  tense  tendon  of  the  biceps  cruris.  A 
primary  neuritis  of  this  nerve  is  by  no  means  rare,  and  even  in  a 
general  neuritis  its  fibers  seem  esi)ecially  liable  to  degeneration. 
Lead  palsy  is  occasionally  limited  to  its  distribution,  especially  in 
children  (Putnam),  but  in  these  cases  the  tibalis  anticus  escapes  as  a 
rule.  Isolated  paralysis  of  this  nerve  is  sometimes  seen  in  tabes 
dorsalis. 

The  whole  limb  must  be  unduly  raised  as  it  is  brought  forward  in 
walking  to  enable  the  toes  to  clear  the  ground.  Inversion  and 
eversion  of  the  foot  are  also  weakened  where  there  is  a  total  pa- 
ralysis. When  the  tibialis  anticus  is  alone  paralyzed  the  foot  can 
be  still  flexed  by  the  long  extensors  of  the  toes,  but  it  is  at  the  same 
time  abducted;  while  if  the  function  of  the  latter  muscle  alone  is 
lost  the  active  tibialis  anticus  inverts  and  adducts  the  foot.  As 
Bernhardt  points  out,  it  not  infrequently  happens  that  the  tibialis 
anticus  escapes  when  the  other  muscles  of  this  group  are  paralyzed. 
The  paralysis  of  the  peroneus  longus  is  most  evident  when  the  ankle 
is  extended,  as  the  foot  is  then  so  strongly  inverted  by  the  unopposed 
action  of  its  extensors  that  its  outer  border  rests  on  the  ground,  and. 
as  the  inner  part  of  the  foot  is  not  supported  during  extension,  flat 
foot  may  develop.  When  all  these  muscles  are  paralyzed  talipes 
equinus  gradually  develops,  oAving  to  contracture  of  their  antago- 
nists ;  if  the  paralysis  of  all  the  muscles  is  not  equal  in  degree  the  foot 
may  be  at  the  same  time  either  inverted  or  everted,  according  to  the 
degree  of  the  paralj^sis  of  the  muscles  with  the  opposing  function. 
The  toes  may  be  permanently  flexed  by  the  contracture  of  the  unop- 
posed flexors  and  interossei.  The  sensory  loss  which  results  from  a 
lesion  of  this  nerve  is  limited  to  the  outer  side  of  the  leg,  the  dorsal 
surface  of  the  foot,  and  the  dorsum  of  the  first  phalanges  of  the  toes. 

The  posterior  tibial  or  internal  popliteal  nerve. — Owing  to  its  deeper 
course  it  is  less  liable  to  injury  than  the  external  popliteal,  and  its 
isolated  paralysis  is  consequently  rarer,  A  few  cases  have  been  re- 
corded in  which  it  has  been  injured  by  the  tendons  of  the  flexors  of 
the  knee  vdien  these  muscles  are  forcibly  contracted  (Oppenheim), 
and  it  may  be  compressed  by  or  involved  in  tumors,  aneurisms,  or 
inflammations. 

The  most  prominent  feature  is  inability  to  extend  the  foot  or  flex 
the  toes,  so  that  the  patient  can  no  longer  stand  on  tiptoe  or  spring 
from  the  forepart  of  the  foot  in  walking;  if  the  paralj^sis  is  of  long 
duration  the  unantagonized  action  of  the  flexors  of  the  ankle  pro- 
duces talipes  calcaneus,  while  the  unopposed  action  of  the  peroneus 


326  WAR   SURGERY    OF    THE    XERVOUS    SYSTEM. 

longus  leads  to  eversion  of  the  foot  and  increases  the  plantar  arch. 
Flexion  of  the  distal  and  middle  phalanges  of  the  toes  is  no  longer 
possible,  owing  to  paralysis  of  the  long  flexors,  while  the  loss  of  the 
interossei.  and  of  the  adductors  and  abductors  of  the  great  and 
small  toes  makes  lateral  movements  impossible.  The  unopposed 
contraction  of  the  long  extensors  may  lead  to  permanent  overexten- 
sion of  the  basal  phalanges. 

When  the  conduction  of  sensory  impressions  is  completely  inter- 
rupted there  is  loss  of  sensation  on  the  outer  side  and  back  of  the 
lower  third  of  the  leg,  on  the  outer  border  of  the  foot,  and  on  the 
sole  and  plantar  surfaces  of  the  toes,  as  well  as  in  the  dorsum  of  the 
distal  phalanges.  There  may  be  trophic  disturbances  and  ulcers 
may  form. 

Paralysis  of  the  main  trunk  of  the  sciatic  nerve  may  be  produced  by 
fractures  of  the  pelvis  or  of  the  upper  end  of  the  femur,  or  by  dis- 
locations of  the  hip- joint ;  or  the  nerve  may  be  compressed  by  tumors 
in  the  pelvis  or  invaded  in  the  extension  of  septic  processes  from  the 
surrounding  tissues.  Some  or  all  of  the  fibers  may  be  paralyzed 
during  parturition,  but  the  lesion  is  then  generally  situated  in  the 
lumbosacral  plexus;  the  sciatic  nerve  of  the  child  may  be  injured 
by  traction  on  the  leg  in  breech  presentations.  The  symptoms  of 
complete  ]3aralysis  by  a  lesion  near  the  sciatic  notch  are  those  of 
parah'sis  of  its  terminal  branches,  the  internal  and  external  popli- 
teal nerves,  with,  in  addition,  palsy  of  the  flexors  of  the  knee.  When 
the  latter  are  powerless  the  limb  must  be  held  extended  at  the  knee 
in  walking,  and  it  can  be  used  only  as  a  stilt;  there  is  no  power  of 
movement  at  the  ankle-joint.  As  all  the  sensory  fibers  enter  its 
terminal  branches,  the  loss  of  sensation  in  a  complete  sciatic  palsy 
includes  the  outer  side  of  the  leg  and  the  whole  of  the  foot  except 
a  small  area  in  the  inner  side  of  the  dorsum. 

The  lumbar  and  sacral  plexuses. — Isolated  paralysis  of  the  lumbar 
plexus  is  extremely  rare  and  merits  no  further  reference,  but  palsy 
of  the  whole  or  part  of  the  sacral  plexus  is  occasionally  met  with. 
It  may  be  due  to  invasion  or  compression  of  some  or  all  of  its  roots 
by  tumors  or  inflammation,  or  the  roots  may  be  injured  b}^  pressure 
from  the  fetal  head  during  birth.  In  the  latter  case  it  generally  is 
only  the  fibers  which  enter  the  external  popliteal  nerve  which  suffer. 
This,  it  has  been  shown  hj  Hunermann  and  Thomas,  is  due  to  the 
fact  that  the  higher  roots  of  the  plexus,  from  which  this  branch  re- 
ceives the  majority  of  its  fibers,  lie  directly  on  the  bone  as  they  pass 
over  the  brim  of  the  pelvis  and  are  consequently  more  liable  to  suffer 
from  compression  than  the  sacral  roots  which  are  separated  from 
the  bone  by  the  pyrif  ormis  muscle.  For  the  same  reason  the  superior 
gluteal  nerve  is  often  injured  at  the  same  time.  But  probably  the 
most  common  causes  of  paralysis  of  these  roots  are  malignant  tumors 


DISEASES   OF   PERIPHERAL   NERVES.  327 

of  the  pelvis,  or  tuberculous  caries,  sarcomata  or  metastatic  carcino- 
mat,a  of  tlie  sacrum,  Avhich  either  compress  or  invade  these  roots  in 
the  intervertebral  canals.  The  symptoms  are  generally  those  of  an 
incomplete  sciatic  paralysis,  but  if  the  upper  roots  are  involved  the 
outward  rotators  of  the  hip  and  the  gluteal  muscles  are  in  addition 
paralyzed ;  or  if  the  lower,  there  will  be  probably  sensory  loss  in 
the  distribution  of  the  small  sciatic  nerve  on  the  back  of  the  thigh 
and  on  the  buttocks  and  perineum. 

Diagnosis. — The  diagnosis  of  disease  of  the  nerves  of  the  lower 
linil)s  is  as  a  rule  easy,  but  different  conditions  with  which  a  partial 
or  complete  jjaralysis  of  the  sciatic  nerve  and  its  branches  mav  be 
confused  needs  further  consideration.  The  diagnosis  is  often  greatly 
dependent  on  the  history  of  the  mode  of  onset  of  the  paralysis  and 
of  its  course;  when  it  immediately  follows  an  injury  in  the  region 
of  the  nerve  there  can  be  little  room  for  doubt  if  the  symptoms  corre- 
spond to  the  portion  of  the  nerve  injured. 

Disease  of  the  sciatic  nerve  and  its  branches  must  be  distinguished  from : 

{1)  Lesions  of  the  sacral  plexus  and  of  the  extradural  yortions  of 
the  lumljosacral  roots. — A^^ien  the  disease  is  situated  in  the  sacral 
plexus,  muscles  other  than  those  supplied  by  the  sciatic  nerve  are 
paralyzed,  as  the  glutei,  the  obturator  internus,  the  gemelli,  and  the 
quadratus  femoris;  and  the  anesthesia  maj^  extend  to  the  back  of 
the  thigh  and  to  the  buttocks  if  the  lower  portion  of  the  plexus  is 
involved.  A  careful  examination  of  the  pelvis  may  reveal  the  pres- 
ence of  a  tumor  or  of  other  disease.  The  extradural  portions  of  the 
sacral  roots  are  most  frequently  involved  by  tumors  or  disease  of 
the  sacrum ;  at  first,  as  a  rule  only  one  root  is  affected  and  the  earliest 
symptom  is  generally  pain,  Avhich  is  often  extremely  severe,  referred 
to  the  peripheral  distribution  of  its  sensory  fibers,  and  paresis  of 
the  muscles  supplied  by  it.  Tlie  neighboring  roots  are  subsequently 
paralyzed,  and  if  the  disease  extends  across  the  middle  line  motor 
and  sensory  symptoms  may  develop  in  the  opposite  limb.  The  dis- 
tinguishing feature,  as  contrasted  with  a  plexus  or  nerve  paralysis, 
is  that  the  motor  and  sensory  symptoms  correspond  in  extent  with 
the  distribution  of  the  root  fibers.  Further,  if  the  lower  sacral  roots 
are  involved  before  they  give  off  their  visceral  branches,  the  bladder 
and  rectum  are  paralyzed ;  true  sphincter  paralysis  never  results  from 
disease  of  the  nerves. 

{2)  From  the  lesions  of  the  cauda  equina  the  paralysis  of  the  nerves 
which  spring  from  the  sacral  plexus  may  be  distinguished  by  the 
fact  that  the  symptoms  in  the  former  are  always  of  the  radicular  and 
not  of  nerve  distribution,  that  they  are  almost  invariably  bilateral, 
and  that  when  the  disease  has  advanced  sufficiently  far  all  the  roots 
below  the  level  of  the  intrathecal  disease  are  generally  involved. 
The  sphincter  functions,  too,  are  almost  invariably  affected.     It  is 


328  WAR  SURGEEY   OF   THE    NERVOUS   SYSTEM. 

more  difficult  to  distingiush  between  disease  of  the  caiida  equina  and 
of  the  extradural  portions  of  the  spinal  roots ;  in  the  latter  condition, 
however,  the  symptoms  are  often  uniradicular  for  a  considerable 
time,  as  the  sacral  disease  to  which  they  are  most  commonly  due  will 
generally  involve  only  one  root  at  the  first.  Another  point  of  dis- 
tinction is  that  all  the  roots  below  the  level  of  the  affected  one  are 
not  paralyzed  in  the  latter  condition,  no  matter  how  long  the  disease 
lasts,  unless  the  sacral  tumor  extends  into  the  vertebral  canal  and 
compresses  the  cauda  equina,  while  when  this  is  primarily  affected 
by  tumor  or  meningitis,  all  the  roots  which  pass  through  the  level 
of  the  disease  are  as  a  rule  compressed, 

(3)  FroTYh  disease  of  the  sacral  segments  of  the  cord  the  diagnosis 
is  easier.  The  symptoms,  as  a  rule,  develop  more  rapidly;  they  are 
almost  invariably  bilateral  and  are  typically  segmental  in  distribu- 
tion, but  all  functions  represented  in  the  segments  below  the  upper 
level  of  the  disease  are  interfered  with.  If.  however,  the  lower  seg- 
ments are  not  involved,  the  paral3'^sis  of  the  muscles  which  they 
supply  is  not  associated  with  atrophy  or  change  in  the  electrical 
recations.  The  severe  radiating  pains,  which  are  an  almost  in- 
variable symptom  of  root  lesions,  are  absent,  and  anesthesia  de- 
velops earlier.  The  sphincter  functions  are  generally  seriouslj' 
affected. 

Sciatica. — This  term  is  commonly  applied  to  all  affections  of  which 
the  chief  symptom  is  pain  in  the  distribution  of  the  sciatic  nerve. 
Such  pain  may  be  of  the  nature  of  a  neuralgia  and  unassociated  with 
any  disease  of  the  nerve,  or  it  may  be  due  to  a  neuritis,  or  to  compres- 
sion of  the  nerve  or  its  roots  by  tumors  or  by  fibrous  adhesions  second- 
ary to  inflammation.  It  is  unfortunate  that  the  one  term  should  be 
used  for  the  symptoms  of  these  different  conditions,  but  it  is,  indeed, 
often  difficult  to  differentiate  between  them.  It  is,  however,  im- 
portant to  separate  the- cases  in  which  there  is  pain  without  any 
evidence  of  organic  disease  in  the  nerve  from  those  in  which  sciatic 
pain  is  associated  with  symptoms  of  a  nerve  lesion,  as  anesthesia 
atrophic  muscular  paresis,  change  in  the  electrical  reactions,  and 
loss  of  the  Achilles  tendon  jerk. 

Etiology. — ^Males  are  affected  much  more  frequently  than  females, 
in  about  the  proportion  of  5  to  1.  It  occurs  more  frequently  in 
middle  life,  and  very  rarely,  if  ever,  under  15  years  of  age.  It  has 
been  attributed  to  almost  innumerable  causes,  but  exposure  to  wet 
and  cold  is  generally  the  only  apparent  exciting  factor;  it  may  fol- 
low sleeping  in  a  damp  bed  or  sitting  on  a  wet  or  cold  seat.  Gowers 
insists  that  many  cases  develop  on  a  gouty  diathesis;  others  un- 
doubtedly follow  spondylitis.  The  disease  may  be  also  due  to  trauma 
to  the  nerve,  as  by  continuous  pressure  on  the  edge  of  a  chair,  a  fall 
on  the  buttock,  or  injury  in  the  neighborhood  of  the  hip  joint.    Occa- 


DISEASES   OF   PERIPHEKAL   NERVES.  329 

sionally  an  attack  sets  in  after  severe  muscular  exertion,  but  probably 
only  in  those  predisposed  to  the  disease.  It  occurs  frecjuently  in 
anemic  and  badly  nourished  subjects  and  in  the  course  of  chronic 
intoxications  (alcohol),  without  any  apparent  exciting  cause,  and 
often  after  infectious  diseases.  Sciatica  may  be  a  symptom  of  dia- 
betes, and  is  then  usually  bilateral.  Quenu  has  shown  that  the  pain 
may  be  due  to  the  pressure  of  varicose  veins  on  the  nerve  in  the 
neighborhood  of  the  sacrosciatic  foramen ;  this  generally  occurs  only 
in  those  who  work  all  da}^  standing  erect. 

Sciatic  pain  may  be  also  due  to  the  presence  of  tumors  or  infiam- 
matorj^  processes  in  the  pelvis,  or  to  a  loaded  rectum,  which  may 
either  directly  compress  the  nerve  or  affect  the  nutrition  by  venous 
stasis  it  produces.  Finally,  pain  in  the  course  of  the  sciatic  nerve 
may  be  due  to  affection  of  its  roots  b}^  disease  of  the  sacrum  or  lesions 
of  the  Cauda  equina.    Hysterical  sciatica  has  been  described. 

The  chief  symptom  is  pain  along  the  course  of  the  nerve,  or  limited 
to  one  of  its  chief  branches.  The  onset  is  occasionally  sudden  and 
associated  with  slight  pj^rexia  and  constitutional  disturbances;  but, 
as  a  rule,  it  sets  in  gradually  with  pain  in  the  buttock  or  back  of  the 
thigh  in  movements  or  in  postures  which  make  the  nerve  tense  or 
cause  pressure  upon  it.  In  other  cases  the  onset  of  the  typical 
severe  pain  is  preceded  by  slighter  diffuse  pain  or  a  feeling  of  dis- 
comfort during  walking  or  after  exercise.  The  pain  increases  grad- 
ually in  severity;  it  maj^  be  either  gnawing  and  burning,  or  sharp 
and  darting  in  character.  As  a  rule,  it  is  constant,  but  severer  par- 
oxysms occur,  either  spontaneously  or  excited  by  movement  of  the 
affected  limb,  and  its  intensity  generally  increases  at  night.  It  may 
be  at  first  limited  to  one  portion  of  the  nerve,  generally  that  in  the 
upper  portion  of  the  thigh,  but  as  the  disease  develops  it  usually 
extends  along  the  whole  length  of  the  sciatic  trunk  and  its  branches. 
Often  bouts  of  pain  occur  which  shoot  from  the  buttock  down  the 
limb ;  such  attacks  maj  be  described  by  the  patients  in  similar  terms 
to  the  lancinating  pains  of  tabes  dorsalis.  It  is  usually  most  intense 
in  certain  points,  as  over  the  sciatic  notch,  in  the  middle  of  the  thigh, 
in  the  popliteal  region,  below  the  head  of  fibula,  and  behind  the 
external  malleolus;  more  rarely  it  is  referred  to  the  region  of  the 
posterosuperior  iliac  crest,  or  is  most  severe  in  the  foot.  The  seat 
of  the  chief  pain  is  often,  however,  variable  in  any  case  from  day  to 
day.  It  is  generally  more  or  less  accurately  limited  to  the  course  of 
the  nerve,  but  in  other  cases  it  is  rsferred  to  its  whole  cutaneous  dis- 
tribution. The  most  comfortable  posture  is  lying  on  the  back  or  on 
the  affected  side,  with  the  thigh  slightly  flexed  and  the  knee  consid- 
erably bent,  and  when  sitting  the  patient  generally  rests  only  on  the 
tuber  ischii  of  the  unaffected  side  with  the  hip  joint  of  the  painful 
limb  extended  as  much  as  possible.    In  walking  the  hip  and  knee  are 


330  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

held  in  moderate  flexion  with  the  foot  extended  at  the  ankle  joint 
and  only  its  toes  and  forepart  touching  the  wound.  Any  sudden 
movement  may  bring  on  an  attack  of  pain. 

The  disease  is  further  characterized  by  the  extreme  tenderness  of 
the  nerve  to  pressure,  rarely  absent,  except,  according  to  Edinger, 
in  those  cases  in  which  the  sciatica  is  due  to  compression  of  the  nerve 
by  distended  veins,  and  in  which  the  spontaneous  pain  disappears 
when  the  patient  lies  at  rest.  In  some  cases  the  muscles  of  the  limb 
are  also  tender  to  pressure.  It  is  characteristic  of  the  pain  that  it  can 
be  invariably  produced  by  stretching  the  nerve;  this  can  be  most 
easily  done  by  flexing  the  thigh  with  the  knee  extended  or  by  extend- 
ing the  knee  when  the  hip  is  flexed,  Lasegue's  sign^  or,  as  Gowers  has 
shown,  by  pressure  on  the  nerve  in  the  popliteal  space  as  the  patient 
sits  in  a  chair  with  the  knee  flexed  to  a  right  angle ;  the  pain  Avhich  is 
produced  by  either  of  these  means  is  felt  not  only  at  the  point  of 
pressure,  but  along  the  course  of  the  nerve  in  the  back  of  the  thigh. 
Bechterew  has  pointed  out  that  full  flexion  of  the  opposite  hip  when 
the  limb  is  extended  at  the  knee  also  often  produces  pain,  but  believes 
this  indicates  disease  of  the  roots  or  of  the  cauda  equina. 

The  pain  is  usually  associated  with  paresthesia.  The  muscles  sup- 
plied by  the  sciatic  nerve  and  its  branches  often  become  flabby  and 
undergo  a  slight  degree  of  general  wasting,  even  in  cases  which  are 
not  due  to  an};-  organic  lesion,  when  the  disease  is  of  long  duration; 
but  in  this  class  of  cases  there  is  no  change  in  the  electrical  excitability 
of  the  muscles.  Severe  reflex  spasms  of  the  limb  and  cramps  in  some 
of  its  muscles,  especially  in  the  calves,  are  not  infrequently  observed. 

Slight  trophic  and  vasomotor  disturbances  are  occasionally  met 
Avith,  but  usually  only  pallor,  dryness,  and  coldness  of  the  skin.  In 
other  cases  there  may  be  an  increase  of  the  surface  temperature  and 
of  sweat  secretion.  Herpes  has  been  observed.  Scoliosis  of  the 
lumbar  spine  convex  to  the  afi^ected  side  is  often  seen,  but  its  imme- 
diate cause  is  in  dispute;  it  may  be  due  to  an  attempt  to  spare  the 
painful  limb  by  tilting  the  center  of  gravity  toward  the  opposite 
side,  or  to  a  relaxation  of  the  lumbosacral  muscles  of  the  affected 
side.  All  explanations  meet  with  the  difficulty  that  the  scoliosis  is 
occasionally  in  the  opposite  direction,  concave  to  the  side  affected. 
Kj^phosis  also  occurs,  but  only  rarely. 

In  addition  to  the  pain  and  tenderness,  evidence  of  organic  disease 
is  present  in  a  considerable  proportion  of  the  cases.  There  may  be 
diminution  of  cutaneous  sensibility,  but,  as  a  rule,  it  is  nothing  more 
than  a  blunting  of  tactile  sensation  on  the  back  of  the  leg  and  on  the 
foot.  When  there  is  an  organic  nerve  lesion  the  hamstrings  and 
leg  muscles  and  occasionallj^  the  glutei  may  be  found  not  merely 
flabby  but  distinctly  wasted  and  weak;  but  the  feebleness  of  move- 
ment due  to  a  true  paresis  must  be  distinguished  from  the  reluc- 


DISEASES    OF    PERIPHERAL    NERVES.  331 

tance  of  the  patient  to  exert  full  power  owing  to  the  fear  of  pain. 
The  most  certain  indication  is  the  presence  of  qualitative  changes 
in  the  electrical  reactions  of  the  Avasted  muscles,  which  must  be 
regarded  as  proof  of  the  existence  of  an  organic  lesion  of  the  nerve. 
The  third  sign  of  the  existence  of  organic  disease  in  the  nerve  is  the 
absence  of  the  Achilles  tendon  jerk.  It  seems  very  doubtful  if  this 
reflex  ever  disappears  in  the  purely  neuralgic  cases ;  in  fact,  in  many 
such  cases  it  is  very  brisk  or  eA''en  exaggerated,  as  both  the  afferent 
and  efferent  paths  of  the  reflex  arc  are  contained  in  the  sciatic  nerve: 
its  diminution  or  disappearance  is  one  of  the  most  delicate  signs  we 
possess  of  the  presence  of  organic  disease  of  the  nerve;  probably  this 
may  be  excluded  in  all  cases  in  which  the  reflex  is  imdiminished. 
The  reflex  seems  to  be  absent  in  about  30  to  40  per  cent  of  the  cases 
which  are  clinically  regarded  as  sciatica  (Strasburger). 

In  the  great  majority  of  the  cases  sciatica  is  unilateral,  but  it  is 
occasionally  bilateral  in  about  7  per  cent  of  all  cases,  according  to 
Gibson's  statistics,  though  Hyde  found  it  in  33  per  cent  of  his  cases. 
This,  as  a  rule,  indicates  a  general  and  not  a  local  exciting  cause ;  it 
occurs  frequently  in  diabetes,  and  may  be  a  part  of  an  incomplete 
general  neuritis. 

Sciatica  has  been  regarded  by  some  recent  authors  as  a  disease  of 
the  dorsal  roots  of  the  cauda  equina.  Dubois  pointed  out  that  the 
hypoesthesia,  when  there  is  any,  may  correspond  in  extent  to  the 
distribution  of  one  or  more  of  the  sacral  roots,  and  Lortat,  Jacob,  and 
Sabareanu  confirmed  his  observations.  The  sensorj^  loss,  according 
to  these  observers,  most  commonl}^  coincides  Avith  tlie  cutaneous  areas 
of  the  last  lumbar  and  the  upper  two  sacral  roots.  In  at  least  two 
of  their  six  cases,  however,  there  was  an  earlier  syphilitic  infection, 
and  in  one  of  these  a  lymphocytosis  of  the  cerebrospinal  fluid  made 
probable  the  existence  of  a  syphilitic  meningitis.  The  fact  that  the 
small  sciatic  nerve  and  more  rarely  the  anterior  crural  and  the 
perineal  nerves  are  occasionally  affected  simultaneously  indicates 
that  the  disease  is  then  not  limited  to  the  sciatic  but  probably  affects 
the  lumbo-sacral  plexus  or  the  spinal  roots.  In  the  latter  case  there 
is  usually  an  excess  of  lymphocytes  in  the  cerebrospinal  fluid,  and, 
according  to  Bonola,  the  fascia  lata  reflex,  which  is  unaffected  in 
sciatica,  is  lost. 

Diagnosis. — The  term  sciatica  is  applied  by  custom  to  cases  in 
which  the  symptoms  are  due  to  an  organic  affection  of  the  nerve, 
as  well  as  to  those  in  which  there  is  no  evidence  of  structural  disease. 
The  first  step  must  be,  however,  to  separate  these  two  classes,  simple 
sciatica  or  sciatic  neuralgia,  in  which  there  is  spontaneous  pain  and 
tenderness  of  the  nerve  to  pressure  and  to  tension,  but  no  pronounced 
sensory  disturbance,  degenerative  atrophy  of  the  muscles,  or  diminu- 
tion of  the  Achilles  tender  jerk;  and  organic  sciatica  or  sciatic  neu- 


332  -       WAE    SUEGEEY    OF   THE    NERVOUS   SYSTEM. 

ritis,  in  which  some  or  all  of  these  signs  of  disease  of  the  nerve  are 
present.  Some  authors,  as  Gowers,  regard  all  cases  of  sciatica  with 
jDersistent  tenderness  of  the  nerve  as  neuritic,  and  consequently  make 
simple  sciatica  or  sciatic  neuralgia  very  rare ;  but  in  facial  neuralgia,  in 
Avhich  there  is  certainly,  as  a  rule,  no  disease  in  the  nerve,  its  trunks 
may  be  quite  as  tender  to  pressure  as  the  nerve  in  sciatica.  Oppen- 
heim  and  others  have  insisted  that  tenderness  of  the  nerves  is  not  a 
differential  sign  between  neuritis  and  neuralgia.  The  pain  of  hip 
disease  may  radiate  a  short  distance  doAvn  the  thigh;  from  sciatica 
it  may  be  distinguished  by  the  absence  of  tenderness  in  the  nerve  to 
pressure  and  tension,  and  the  occurrence  of  pain  on  movement  of 
the  hip  joint,  and  on  pressure  on  the  trochanter.  Disease  of  the 
sacro-iliac  synchondrosis  may  be  more  difficult  to  recognize. 

Although  many  cases  of  sciatica  are  due  to  a  neuritic  or  morbid 
process  in  the  nerve,  the  presence  of  marked  sensory  disturbance  and 
degenerative  atrophy  of  the  muscles,  with  the  absence  of  the  Achilles 
tendon  jerk,  should  always  raise  the  suspicion  of  more  serious  disease. 
If  it  is  due  to  the  compression  of  the  nerve  or  its  roots  by  a  tumor 
in  the  pelvis,  the  sciatic  trunk  is  not  tender  to  pressure. 

When  the  sacral  roots  are  involved  in  disease  of  the  sacrum  or  of 
the  cuuda  equina,  the  symptoms  are  generally  Inlateral  and  more 
irregular  in  distribution,  and  the  functions  of  the  sphincters  are, 
as  a  rule,  affected ;  the  pain  is  also  generally  referred  to  the  cutaneous 
distribution  of  the  affected  fibers ;  the  sensory  or  motor  disturbances 
correspond  to  root  distribution,  and  the  nerve  trunk  is  not  tender. 

In  the  earl}^  stages  of  tabes  dorsalis  the  shooting  pains  may  be 
limited  to  the  sciatic  distribution,  but  a  careful  examination  of  the 
case  will  generally  reveal  characteristic  signs ;  in  it  the  pain  is  almost 
invariably  bilateral,  and  the  nerves  are  not  tender  to  pressure  or 
stretching. 

The  pain  of  intermittent  claudication  occurs  only  after  exercise  and 
is  generally  most  intense  in  the  distal  segments  of  the  limbs  and  is  not 
limited  to  the  course  of  the  nerves. 

Prognosis. — In  simple  sciatica  this  is  good  as  regards  ultimate  re- 
covery, but  it  is  extremely  difficult  to  predict  the  duration,  although 
as  a  general  rule  it  is  proportional  to  the  severity.  Cases  in  which 
pain  is  associated  with  signs  of  an  organic  nerve  lesion  are  less 
favorable  than  the  uncomplicated  neuralgic  cases.  The  outlook  is 
less  favorable  in  eases  of  long  duration  and  where  adequate  treat- 
ment is  not  possible.  ^¥here  the  sciatic  pain  is  due  to  some  lesion 
extrinsic  to  the  nerve  which  compresses  or  injures  it,  the  prognosis 
is  naturally  dependent  on  the  nature  of  the  primary  disease.  Re- 
lapses are  unhappily  not  infrequent. 

Treatment. — The  first  essential  in  all  cases  is  reM.  Even  in  mild 
cases  this  should  be  made  as  absolute  as  possible  for  some  days  at 


DISEASES  OF   PEEIPHEBAL   NERVES.  333 

least,  and  if  it  is  adopted  earl}^,  severe  cases  may  be  often  converted 
into  slight  ones.  The  patient  should  be  confined  t<j  bed  and  all  move- 
ments of  the  affected  limbs  should  be  restricted  as  far  as  possible,  if 
necessary,  by  a  long  splint.  This  treatment  is  applicable  not  merely 
to  recent  cases;  obstinate  and  protracted  cases  which  have  resisted 
all  other  treatment  often  yield  readih^  to  it.  It  is  often  necessary 
to  continue  it  four  to  six  weeks,  or  even  longer,  without  break.  Where 
it  is  not  possible  to  obtain  such  complete  rest,  an  effort  should  be  at 
least  made  to  avoid  all  movements  which  give  pain  and  cause  stretch- 
ing of  or  pressure  on  the  nerve. 

Constitutional  conditions,  which  are  often  predisposing  causes, 
should  receive  adequate  treatment.  In  some  of  the  acute  cases  the 
salicylates  relieve  the  symptoms ;  iron  and  arsenic  often  prove  useful 
in  cases  with  anemia.  The  rectum  should  be  emptied  and  constipa- 
tion avoided. 

In  acute  stages  the  application  of  hot  poultices  along  the  course  of 
the  nerve  may  ease  the  symptoms.  Counterirritation  by  the  applica- 
tion of  the  cautery  or  by  blisters  over  the  course  of  the  nerve  is  very 
generally  employed,  and  often  seems  to  be  of  distinct  value.  Baths, 
douches,  and  especially  the  hot-air  bath,  undoubtedly  give  relief  smd 
often  intJuence  the  course  very  favorably,  especially  in  its  most  chronic 
stages.  When  there  is  acute  pain,  symptomatic  treatment  may  be 
forced  into  the  first  place.  Antipj^rine,  phenacetin.  and  such  drugs 
often  give  relief  for  a  time.  Occasionally  deep  injections  of  morphine 
or  cocaine  into  the  nerve  mny  be  necessary,  but  they  are  only  tem- 
porary measures,  and.  owing  to  the  nature  of  the  disease,  there  is 
always  a  considerable  danger  of  a  drug  habit.  Morphine  is  the  most 
effective,  but  cocaine  in  closes  of  from  one-eighth  to  one-fourth  of  a 
grain  may  abolish  all  pain  for  hours. 

Favorable  results  have  been  obtained  by  the  injection  of  relatively 
large  quantities  of  normal  saline  solution  (50  to  100  c.  c.)  into  the 
sheath  of  the  nerve.  The  injection  is  made  in  the  upper  part  of  the 
thigh;  severe  pain  referred  peripheralward,  paresthesia,  and  mus- 
cular spasm  of  the  limb  indicate  when  the  needle  enters  the  nerve. 
The  acute  pain  disappears  rapidly  when  the  injection  is  commenced, 
which  should  be  made  slowly.  More  than  two  or  three  injections  are 
rarely  necessary,  and  often  one  is  sufficient.  Bum  recorded  the  re- 
sult of  this  in  78  cases;  he  obtained  a  complete  cure  in  42,  and  14 
were  much  improved. 

Half  a  gramme  of  antipyrine  dissolved  in  an  equal  weight  of  dis- 
tilled water  has  been  also  recommended  as  a  local  injection  into  the 
nerve.  Excellent  results  have  been  also  ol)tained  by  the  injection  of 
10  to  li")  c.  c.  of  physiological  salt  solution,  or  1  per  cent  cocaine  or 
4  per  cent  stovaiue,  into  the  epidural  space  by  Catlielin's  method 
(Heile). 


334  WAR   SURGERY   OF   THE   NERVOUS  SYSTEM. 

The  galvanic  current  is  often  useful  in  the  later  stages;  one  large 
electrode  should  be  placed  oA^er  the  nerve  in  the  upper  part  of  the 
thigh,  the  other  on  the  leg  over  one  of  its  branches  or  on  the  foot, 
and  a  constant  current  of  3  to  5  milliamperes  employed  for  5  to  20 
minutes. 

It  is  rarel}^  advisable  to  use  massage  in  acute  cases,  but  when  the 
muscles  become  flabby  or  atrophied  it  is  of  service,  but  pressure  or 
tension  of  the  nerve  must  be  carefully  avoided.  Acupuncture  may 
be  tried;  a  series  of  six  or  more  sterilized  needles  are  thrust  in  to 
a  depth  of  about  2  inches  along  the  course  of  the  nerve  in  the  upper 
half  of  the  thigh  and  left  there  from  20  minutes  to  an  hour.  Many 
of  the  needles  may  pierce  the  nerve,  but  if  they  are  inserted  from 
above  downward  only  the  first  one  causes  much  pain. 

Nerve  stretchmg  has  also  fallen  out  of  fashion,  and  probably 
rightly,  but  it  may  be  necessary  to  have  recourse  to  it  in  very  obstinate 
cases.  Bardenheurer  has  suggested  cutting  away  the  brim  of  the 
sciatic  notch  where  the  nerve  passes  over  it  in  order  to  leave  the  latter 
embedded  in  the  soft  tissues  and  free  from  pressure. 

Diseases  of  the  spinal  roots. — The  spinal  roots  may  be  affected  by 
disease,  either  inside  the  dura  mater  or  in  their  extrathecal  course. 
before  they  anastomose  to  form  the  plexuses.  The  lesions  of  the 
latter  portions  have  been  considered  under  the  plexus  lesions  and 
the  diseases  of  the  cauda  equina  are  dealt  with  in  another  section. 
The  disease  of  the  roots  may  be  primary  or  the  symptoms  may  be 
caused  by  compression  or  extension  of  disease  from  the  surrounding 
parts. 

Primary  root  lesions  are  extremely  rare.  One  root  alone  may  be 
injured  by  a  tumor  in  the  neighborhood  of  the  vertebral  column, 
as  frequently  happens  in  malignant  disease  in  this  region,  or  spinal 
caries.  Supernumerary  ribs  may  produce  an  isolated  palsy  of  the 
first  thoracic  nerve.  But,  as  Dejerine  and  his  pupils  have  pointed 
out,  root  lesions  are  more  frequently  secondary  to  intradural  disease. 
and  especially  to  compression  and  the  invasion  of  them  by  local 
tuberculous  or  sjq^hilitic  meningitis.  A  single  root,  either  sensory 
or  motor,  only  may  be  affected,  but  more  commonl}^  several  roots  are 
involved.  There  are  frequently  signs  of  associated  disease  of  the 
spinal  cord. 

The  distinguishing  feature  of  all  root  lesions  is  the  limitation  of 
the  symptoms  to  disturbance  of  the  functions  of  the  motor  or  sensorj' 
fibers  of  the  root  or  roots  affected ;  this  distinguishes  root  lesions  from 
lesions  of  the  peripheral  nerves,  which  almost  invariably  contain 
fibers  of  two  or  more  roots.  The  onset,  which  may  be  either  acute 
or  slow,  is  generally  at  first  paroxysmal  but  may  become  continuous, 
is,  as  a  rule,  very  severe  and  of  the  same  darting  or  shooting  character 
as  the  pains  of  tabes  dorsalis.     If  it  is  the  intradural  portions  of  the 


DISEASES   OF    PERIPHERAL    NERVES.  335 

roots  which  are  affected,  sneezing  or  coughing  ma}'  i)ro(luce  very 
acute  pain  in  the  affected  root  areas  (signe  de  I'eternuenient)  owing 
to  the  effect  of  the  sudden  increase  of  the  intradural  pressure  on  the 
irritable  fibers.  After  a  variable  time  the  i)ain  graduall,y  diminishes, 
and  the  skin  which  was  previously  hyperesthetic  become  hypesthetic 
as  the  sensory  root  fibers  degenerate  or  are  destroj'ecl.  When  only  one 
root  is  involved  this  diminution  of  sensibility  may  escape  notice 
owing. to  the  considerable  overlap  of  the  adjacent  root  fibers;  it  is 
largely  dissociative  in  character,  the  loss  of  pain  sensation  being,  in 
contrast  to  the  condition  found  after  peripheral  nerve  lesions,  more 
extensive  than  the  insensibility  to  light  touch  (Head).  Simultar 
neously  with  the  appearance  of  hypesthesia  the  muscles  supplied  by 
fibers  from  the  affected  ventral  root  or  roots  become  paretic:  and 
if  the  lesion  is  sufficiently  intense  they  atroplw  and  changes  in  their 
electrical  reactions  develop ;  but  as  almost  all  muscles  receive  fibers 
from  two  or  more  roots  the  paralysis  of  any  muscle  is  rarely  com- 
plete if  the  lesion  is  uniradicular.  Cutaneous  trophic  changes  have 
been  observed  in  the  area  of  sensory  distribution  of  the  affected  roots, 
probably  in  cases  in  which  the  root  ganglia  have  been  involved,  and 
the  ocular  symptoms  of  irritation  or  paresis  of  the  cervical  sympa- 
thetic fibers  may  appear  when  the  lower  cervical  and  upper  dorsal 
roots  are  affected. 

Diagnosis. — This  depends  on  the  essentially  radicular  distribution 
of  the  symptoms.  Spinal  diseases,  as  tabes  dorsalis,  syringomyelia, 
and  local  lesions  may  produce  symptoms  of  this  distribution,  but 
these  can  rarely  offer  any  difficult}^  From  local  neuritis  of  a  periph- 
eral nerve  it  may  be  also  distingiushed  by  the  fact  that  the  nerve 
trunks  are  never  very  tender  to  pressure.  When  the  primary  disease 
is  a  meningitis  which  invades  or  constricts  the  roots  lumbar  punc- 
ture may  aid. 

Treatment. — This  should  be  directed  to  removing  the  cause;  surgi- 
cal intervention  ma}^  be  successful  in  the  case  of  tmnors,  and  if  there 
are  other  symptoms  of  meningitis  vigorous  antisyphilitic  treatment 
should  be  adopted  if  syphilitic  infection  can  not  be  excluded.  In 
cases  with  persistent  pain  the  intradural  section  of  the  dorsal  roots 
may  be  necessary. 


Part  2. 

ABSTRACTS  FROM  THE  ENGLISH,  GERMAN,  AND  FRENCH 
LITERATURE  ON  NERVE  INJURIES  IN  WAR. 

One  law  that  can  be  laid  down  as  a  result  of  the  study  of  the  litera- 
ture of  war  injuries  of  the  nervous  system  is  that  the  more  peripheral 
the  injury  the  more  unanimous  are  the  opinions  of  surgeons  regarding 
the  principles  of  adequate  treatment.  We  have  noticed  the  marked 
diversity  of  views  in  head  surgery,  as  contrasted  with  the  much  less 
pronounced,  though  still  plainly  evident,  differences  of  opinion  re- 
garding the  treatment  of  spinal  injuries.  Eegarding  the  peripheral 
nerve  injuries,  practically  all  authors  are  agreed  that  emergencj^  op- 
eration is  practically  never  indicated  and  that  a  leisurely  careful 
study  of  sjanptoms  is  always  in  order ;  that  it  is  often  impossible  to 
determine  soon  after  the  reception  of  the  injury  whether  the  nerve  is 
totally  divided,  incompletely  divided,  or  even  whether  it  is  in  the 
slightest  degree  organically  impaired.  All  are  in  pretty  fair  agree- 
ment, moreover,  in  insisting  upon  delicate  operative  manipulations, 
excision  of  scar  tissue,  and  freeing  of  the  nerve  ends.  It  is  also 
thoroughly  agreed  that  much  of  the  success  following  nerve  suture 
depends  upon  proper  after  care.  Most  of  the  later  articles  recom- 
mend tubulization.  On  only  one  point  does  there  seem  to  be  much 
diversity  of  opinion,  namely,  final  outcome  after  nerve  suture;  re- 
garding this  it  must  be  said  that  too  short  a  time  has  elapsed  to  judge 
the  postoperative  results  accurately.  One  notes  in  passing,  however, 
that  one  author  reports  complete  restitution  tico  toeeks  after  nerve 
suture,  whereas  most  operators  expect  little  for  from  6  to  24  months 
after  operation.  One  author  reports  75  per  cent  of  good  results  and 
another  one  (who  tubulized)  reports  failure  to  secure  restoration  of 
motion  in  a  single  one  of  19  operated  cases. 

The  physiological  processes  underlying  nerve  regeneration  and 
nerve  transplantation  are  so  poorly  understood  that  we  have  included 
as  introductory  abstracts  the  papers  of  Lewis  and  Kirk  and  Inge- 
brigtsen. 

Kirk,  E.  G.,  and  Lewis.  D.  D.:     Regeneration  in  Peripheral  Nerves; 

an    Experimental    Study.      l',itU.    Jolnis    Ihiiikius    llo-^p..    V.ni. 

xxviii,  71. 

It  has  been  shown  by  the  authors  that  nerve  defects  may 

be  bridged  successfully  by  tubulizing  with  an  autotransplant 

of  fascia.     Although'  devised  primarily  with  reference  to 

336 


FOREIGN    WAR    LITERATURE.  337 

practical  surgical  use,  it  soon  became  apparent  to  them  that 
the  method  afforded  unusual  opportunities  for  a  study  of 
the  histology  of  nerve  regeneration  following  mechanical 
trauma.  The  defect  was  produced  by  excising  a  segment, 
varying  in  length  from  1  to  3  centimeters,  the  nerve  being  cut 
squarely  across  with  a  sharp  knife.  Fascia  lata  from  the 
same  animal  was  used  to  construct  the  tube,  since  by  using 
an  autotransplant  fibroblastic  reaction  and  subsec{uent 
cicatrization  were  avoided.  Thus  regeneration  following 
trauma  could  be  studied  without  interferencB  from  various 
external  factors  and  in  particular  the  ingrowth  of  cicatricial 
tissue  between  the  ends.  Most  important  of  all,  the  com- 
parative behavior  of  proximal  and  distal  stumps  w^as  more 
easily  determined  than  when  the  ends  were  approximated. 

The  material  used  in  the  present  report  included  41 
sciatic  nerves  of  adult  dogs,  21  of  which  Avere  in  complete 
serial  section.  The  animals  were  killed  at  periods  varying 
from  one  day  to  36  weeks  after  operation. 

The  various  methods  of  histological  preparation  for  the 
study  of  the  tissues  are  described  by  the  authors  in  this 
paper.  In  conclusion  they  state  that  in  the  immediate 
vicinity  of  nerve  trauma  associated  with  break  of  conti- 
nuity there  occurs  an  accelerated  hyperplasia  of  the  neuri- 
lemmal  elements  which  results  in  the  early  formation  of 
protoplasmic  bands,  which  develop  in  both  the  proximal 
and  distal  stumps  and  tend  to  bridge  the  defect.  Along 
these  protoplasmic  pathways  the  regenerating  axis  cylinders 
from  the  central  stump  pass.  Whether  they  reach  the  distal 
stump  and  neurotize.  the  authors  state,  depends  largely  on 
the  extent  to  which  these  preformed  conduits  have  prepared 
the  way. 

All  efficient  regeneration  of  nerve  fibers  (axis  cylinders) 
is  from  the  central  stump,  the  authors  believe,  and  all  regen- 
erating nerve  fibers,  whether  the  outgrowth  of  medullated  or 
of  nonmedullated  axones,  are  in  their  early  stages  non- 
meduUated. 

They  found  that  all  meduUation  began  proximally  and 
proceeded  distally,  appearing  only  in  those  parts  of  the  new 
axis  cylinder  which  had  acquired  an  age  of  five  or  five  and 
one-half  weeks  (in  the  dog). 

Lewis  has  described  and  illustrated  the  technique  of  fascial 
tubulization  in  Surgery^  Gynecology^  and  Ohstetrics^  Feb- 
ruary, 1917,  page  127. 

Ingebrigtsen,   R.:    A    Contribution   to   the   Biology    of   Peripheral 
Nerves  in  Transplantation.    J.  Exp.  Med.,  1915,  xxii,  418. 

From  this  experimental  study  the  author  draws  the  fol- 
lowing conclusions: 

Heteroplastic  transplanted  nerves  become  necrotic.  They 
are  unsuitable  for  bridges  in  cases  of  nerve  defects,  and  his 
results  explain  the  failure  of  the  attempts  at  heteroplastic 
transplantation  of  nerves  in  human  beings. 

13764—17 ^22 


338  WAR   SURGERY   OF   THE    NERVOUS  SYSTEM. 

If  it  is  desired  to  bridge  a  nerve  defect  by  implantation, 
autoplastic  or  homoplastic  grafts  must  be  used.  The  occur- 
rence of  a  Wallerian  degeneration  in  these  grafts  during  the 
first  two  or  three  weeks  after  the  transplantation  should 
make  bridging  a  promising  operation,  for  in  this  period  the 
grafts  resemble  the  peripheral  part  of  a  divided  nerve  and 
must  be  assumed  to  be  capable  of  regeneration,  and  thus  are 
very  different  from  dead  material. 

The  author  has  studied  the  process  of  regeneration  and 
in  a  future  article  will  communicate  his  results  of  bridging- 
defects,  which  are  encouraging  so  far  as  the  function  is 
concerned. 


The  contribution  by  Tubby  is  important  as  an  attempt  to  formu- 
late an  exact  definition  of '"nerve  shock"  (a  condition  similar  to 
spinal  shock)  and  the  pathological  changes  incident  thereto.  It  also 
emphasizes  the  importance  of  proper  orthopedic  measure  and  massage 
and  electricity  in  the  aftercare  of  nerve  injuries. 

Tubby,  A-  H.:    Nerve  Concussion  Due  to  Bullet  and  Shell  Wounds. 

Brit.  M.  J.,  1915,  i,  57.    By  Surg.,  Gyuec.  &  Obst. 

In  reporting  cases  of  nerve  injury  under  his  care  at  the 
Fourth  London  General  Hospital,  Tubby  states  that  it  is  a 
little  difficult  to  gather  what  is  the  general  acceptation  of  the 
vague  term  "  concussion  of  nerve.''^  He  thinks  the  following 
definition  may  prove  acceptable :  "  It  is  damage  done  to  a. 
nerve  trunk  without  actual  destriiction  of  the  axis  cylinders; 
and  the  damage  mag  consist  of  an  effusion  of  hlood  between 
the  fibers  following  compression  of  the  nerve  against  a  bone 
by  the  rapid  passage  of  «.  foreign  body  in  the  immediate 
neighborhood  of  the  nerve.  In  other  cases  the  actual  lesion 
may  not  amount  to  hemorrhage.^  but  to  a  temporary  anemia., 
or  its  opposite^  hyperemia  of  the  nerve.,  and  specimens  are 
required  for  microscopical  examination  before  a  precise 
diagnosis  can  be  made.  It  is  also  possible  to  conceive  that 
in  certain  large  nerve  trunks,  such,  for  instance,  as  either  of 
the  popliteal  nerves,  where  the  motor  fibers  can  be  split  up 
for  a  very  long  distance  from  the  sensory,  either  a  motor 
or  a  sensory  bundle  may  be  injured,  so  that  in  one  case 
motor  paralysis  alone  may  exist  and  in  another  sensory 
symptoms  be  present." 

In  all  cases  stereoscopic  skiagrams  were  taken.  A'\^iere 
possible  or  practicable  the  shell  fragment  or  bullet  was  re- 
moved, especially  if  it  was  near  some  large  nerve  trunk. 
Tubby  says  these  physiological  paralyses  will  clear  up.  A 
partial  or  irregular  paralysis  of  muscles  supplied  by  one 
nerve  trunk  is  indicative  of  a  physiological  blocking  such 
as  arises  from  a  small  hemorrhage  in  or  around  a  nerve 
trunk  or  a  bruising.  A  persistence  of  the  reaction  of  de- 
generation is  an  indication  for  exploration  of  the  nerve. 
While  waiting  for  the  power  to  return  he  emphasizes  the 
necessity  of  relaxing  paralyzed  muscles;  e.  g.,  wrist  drop 


FOREIGN  WAR  LITERATURE.  339 

to  liyperextend  on  a  splint,  foot  drop  to  dorsiflex  the 
foot  beyond  a  right  angle.  Massage  and  electricity  should 
be  given  in  these  same  position. 


The  following  abstracts  speak  for  themselves  and  require  no  criti- 
cal comment. 

Nonne,  M.:  War  Injuries  of  Peripheral  Nerves   (  I  Ixt  Kieigsvei-let- 
zuiigen  tier  periplieren  Nerven).     Med.  Klin..  Ji<i!.,  l'.»15,  xi,  HOI. 

The  number  of  injuries  to  nerves  is  so  great  in  the  present 
war  that,  after  they  have  been  collected  and  compared,  the 
knowledge  of  diagnosis  and  treatment  in  such  cases  will  be 
greater  than  ever  before.  Not  only  are  the  numbers  greater 
but  the  soldiers  can  be  kept  under  observation  and  after- 
treatment  administered  better  than  in  hospitals  in  time  of 
peace.  Nonne  has  found  that  the  nerve  is  completely  sev- 
ered much  more  frequently  than  is  usually  supposed.- 
Sometimes  the  severed  ends  are  separated  by  as  much  as 
4,  5,  or  6  cm.  Often  the  gap  is  filled  in  with  cicatricial 
tissue  or  callus. 

In  cases  where  it  is  evident  that  the  nerve  is  completely 
severed,  operation  should  be  performed  early.  If  the  nerve 
injury  is  complicated  by  fracture  or  other  wounds,  operation 
should  be  delayed  till  these  are  healed.  But  in  the  majority 
of  cases  it  is  im])ossihle  to  determine  hy  nein-ological  ex- 
am^ination  whether  the  nerve  is  severed;  the  reaction  of  de- 
generation and  disturbances  of  sensation  and  motility  may 
be  as  great  in  cases  of  severe  contusion  or  concussion.  In 
such  cases  there  should  he  a  delay  of  six  or  eight  toeeks  to 
see  if  function  im/proves  luithout  opeTation;  if  not,  operate. 

The  nature  of  the  operation  will  depend  on  the  condition 
of  the  nerve.  Neurolysis  is  sufficient  if  the  nerve  is  onlj^ 
strangulated  or  embedded  in  cicatricial  tissue.  If  it  is  sev- 
ered the  ends  should  be  freshened  and  sutured.  If  the  ends 
are  too  far  separated  to  be  rejoined  a  piece  of  nerve  may  be 
grafted  in.  In  taking  hold  of  the  nerves  with  forceps  only 
the  sensory  fibers  should  be  seized;  an  accurate  knowledge 
of  the  topography  of  the  cross  section  of  the  different  nerves 
is  necessary.  Sometimes  muscles  react  normallj^  to  the  gal- 
vanic current  and  show  the  reaction  of  degeneration  with 
the  galvanic,  and  vice  versa.  Sometimes  part  of  the  muscles 
innervated  by  the  nerve  show  the  reaction  of  degeneration 
while  others  react  normally;  it  is  necessarj^  to  examine  all 
the  muscles  carefully. 

Attention  is  called  to  the  frequency  with  tohich  organic 
lesions  are  simulated  hy  hysteria,  and  the  author  reports  a 
number  of  cases  in  which  he  cured  the  paralysis  following 
an  injury  by  suggestion.  He  suspected  hysteria  because  the 
tendon  reflexes  were  normal.  It  may  be  necessary  to 
anesthetize  the  patient  to  eliminate  the  hysterical  element. 
After  treatment  in  the  form  of  electricity,  massage,  exercise, 
hot  air,  and  hot  water  is  of  great  importance  in  nerve 
injuries. 


340  WAR  SURGERY   OF   THE    NEEVOUS   SYSTEM, 

Hoffmann:  Operations  on  the  Peripheral  Nerves  (Uusere  Eifjili- 
rungeii  init  der  chirurgiseheii  Bebaiullung  tier  Schues-sverlet- 
zuugen  periphereii  Nerveu).  AIuciicJicii,  incd.  Wchnsichr.,  1916, 
No.  34,  Aug.  22. 

The  indications  for  surgical  intervention  are :  (1)  Complete 
motor  paralysis  with  total  reaction  of  degeneration;  (2) 
partial  motor  paralysis,  when  after  two  or  three  months  con- 
ditions remain  unchanged  or  worse;  (3)  severe  sensory  irri- 
tative symptoms  in  the  domain  of  the  nerve  which  do  not 
improve  under  treatment;  (4)  trophic  disturbances,  espe- 
cially retardation  of  healing  of  wounds  in  the  domain  of 
the  affected  nerve. 

The  most  suitable  time  for  intervention  is  decided  by  the 
following  indications : 

(1)  The  wounds  caused  by  gunshot  and  their  complica- 
tions must  be  quite  cured,  as  a  good  result  of  nerve  suture 
can  not  be  hoped  for  unless  in  aseptic  conditions.  Even 
after  apparent  recovery  germs  may  still  be  vital  in  a 
cicatrix,  especially  in  fracture  cases,  and  in  such  cases  it  may 
be  necessary  to  delay  intervention  for  eight  or  nine  months 
until  complete  recovery  and  an  aseptic  condition  is  quite 
assured. 

(2)  Cases  in  which  a  grave  nerve  lesion  is  evident  should 
be  operated  upon  as  soon  as  possible  after  recovery  of  the 
wound.  Within  two  months  15  such  cases  were  operated 
upon. 

(3)  All  other  cases  should  be  operated  on  after  a  period 
of  two  to  three  months  if  there  is  no  improvement  in  the 
nervous  disturbances.  Forty-seven  such  cases  v\'ere  operated 
upon  two  months  or  more  after  injury. 

In  technique  the  following  points  require  attention:  To 
approach  the  nerve  with  the  least  injur}^  of  soft  parts;  to 
respect  the  muscle  nerve  branches;  rigorous  hsemostasis 
using  P]smarch's  band ;  to  proceed  under  general  anesthesia. 

In  58  of  the  cases  the  author  practiced  wrapping  of  the 
sutured  tract  or  of  the  parts  of  the  dissected  nerve  in  a  piece 
of  free  transplanted  fascia  lata  taken  from  the  thigh  of  the 
patient;  it  is  necessary  to  include  a  large  part  of  the 
aponeurosis  in  wrapping  the  nerve  in  order  to  avoid  the 
following  retraction  which  is  always  observed  with  nerve 
compression  and  its  consequences.  The  wrapping  fascis  is 
fixed  by  suturing  its  margins  together,  and  its  extremities 
are  sutured  to  the  surrounding  tissues.  The  author  thinks 
that  merely  placing  the  nerve  in  the  midst  of  muscular 
tissue  is  not  the  method  of  choice  and  refers  to  a  case  oper- 
ated upon  by  others  in  which  the  sciatic  nerve  was  so  treated. 
The  patient  showed  grave  sensory  irritative  phenomena  with 
advanced  atrophy  and  flexional  contracture.  Having  freed 
the  nerve  which  he  found  adherent  to  the  muscle,  the  author 
wrapped  it  in  a  fascial  transplant  and  after  theree  weeks 
the  pain  had  disappeared  and  the  patient  could  move  the 
limb. 

Of  the  end  results,  only  a  few  particulars  can  be  given 
owing  to  the  necessity  of  clearing  the  patients.    In  11  cases 


FOEEIGN    WAR   LITEKATURE.  341 

of  suture  he  had  good  results  with  return  of  function  in 
periods  varying  from  2  to  12  months.  In  7  cases  the  results 
were  uncertain;  4  gave  no  results;  and  in  8  the  time  after 
operation  is  too  short  to  give  an  opinion.  In  the  19  cases  of 
nerve  liberation,  14  were  successful,  2  doubtful,  3  gave  no 
results. 


Ferrand,  J.:  Neurology  in  War  (Keflexions  meclico-cblrurgicales  sur 
la  pratique  neurolojiiqiie  en  temps  de  f^uerre).  •/.  dc  radial. , 
1915,  i,  629. 

Injuries  of  the  large  nerve-trunks  are  very  frequent.  The 
diagnosis  is  easily  made,  but  the  wounds  rarely  heal  without 
suppuration,  which  renders  operation  on  the  nerve  impos- 
sible. Operations  for  the  repmr  of  nerves  should  never  he 
undertaken  within  the  first  two  months  after  injury.,  and 
sometimes  even  longer. 

When  it  comes  to  considering  the  question  of  operation 
there  are  three  classes  of  cases : 

1.  Those  in  which  the  nerve  is  merely  compressed  by 
cicatricial  tissue.  Motor  paralysis  is  not  complete;  there  is 
not  complete  reaction  of  degeneration  or  vermicular  con- 
traction, but  sometimes  there  is  extreme  pain.  Operation  is 
indicated  in  these  cases  and  is  very  successful.  The  nerve 
is  freed  from  scar  tissue,  displaced  so  that  it  runs  through 
normal  muscle,  and  the  wound  closed  aseptically. 

2.  Those  cases  in  which  the  nerve  is  partially  severed. 
In  these  there  is  little  or  no  pain  and  no  trophic  disturb- 
ance; paralysis  corresponds  only  to  the  fibers  that  are  sev- 
ered. These  cases  should  not  be  operated  upon.  The  normal 
fibers  serve  as  a  guide  along  which  the  severed  fibers  are 
gradually  reconstructed.  Animal  experimentation  as  well  as 
clinical  experience  has  shown  that  such  reconstruction  does 
take  place.  Electrotherapy  is  the  sovereign  treatment  in  this 
group. 

3.  Those  in  wdiich  the  nerve  is  completely  severed.  In 
these  cases  motor  paralysis  is  absolute  in  all  the  muscles  in- 
nervated by  the  nerve  in  question.  There  is  also  anesthesia, 
complete  reaction  of  degeneration  in  the  peripheral  end, 
and  trophic  disturbances  begin  to  appear. 

Opinions  are  divided  as  to  the  advisability  of  operation. 
Ferrand  is  inclined  to  think  it  is  generally  not  indicated. 
When  it  is  performed  there  is  apt  to  be  neuritis  of  the 
peripheral  end,  wdiich  interferes  with  regeneration.  This  is 
especially  apt  to  occur  in  the  painful  cases,  so  that  it  is  in 
these  that  operation  is  most  contra-indicated.  Some  oper- 
ators resect  all  scar  tissue  and  resect  the  severed  ends,  but 
the  author  believes  that  such  resection  is  rarely,  if  ever,  suc- 
cessful; he  favors  the  more  conservative  method  of  simj^ly 
dissociating  the  fhers  from  cdl  fibrous  tissue,  leaving  them 
to  form,  a  bridge  for  the  reconstruction  of  nev)  nerve-fibers. 
Careful  electrical  examination  is  the  most  important  point 
in  making  a  differential  diagnosis  of  the  different  classes  of 
injury. 


342  WAR  SURGERY  OF   THE   NERVOUS  SYSTEM. 

Thoele:  Injuries  of  Peripheral  Nerves  in  War  (Kriegsverletzungen 
peripherei-  Nerven).     Bcitr.  ;?.  klin.  CMr.,  1915,  xcviii,  131. 

Thoele  devotes  125  pages  to  an  exhaustive  discussion  of 
nerve  injuries  during  the  war.  He  has  operated  upon  46 
cases.  He  found  that  in  about  half  of  his  cases  the  nerve 
was  completely  severed,  a  higher  percentage  than  is  given 
by  most  authors.  The  radial  was  injured  more  frequentlj^ 
than  any  other  single  nerve.  It  was  impossible  to  tell  clin- 
ically whether  the  nerve  was  completely  severed  or  not. 

The  results  of  48  operations  are  reported;  two  patients 
w^ere  injured  in  two  different  regions  and  had  two  different 
operations  performed.  Neurolysis  was  performed  in  17 
cases,  9  simple  and  8  complicated.  In  the  9  simple  cases 
there  were  only  two  complete  recoveries.  In  a  third  case  the 
paralysis  of  the  ulnar  recovered,  but  with  contracture  of  the 
third  to  the  fifth  fingers.  In  3  more  cases  there  w^as  marked 
improvement  which  will  eventually  probably  be  complete  re- 
covery. There  was  slight  improvement  in  1  case  and  no 
improvement  in  2.  Of  the  8  complicated  cases  there  was 
slight  improvement  in  4  cases  and  very  marked  improvement 
in  4. 

In  11  cases  of  complete  severing  of  the  nerve  the  ends  were 
fi'eshened  and  sutured.  There  was  improvement  in  only  4 
of  these  cases;  complete  recovery  in  none.  In  10  cases  the 
nerves  were  cut  and  sutured  on  account  of  spindle-shaped 
thickening;  they  were  only  partially  severed.  There  is  be- 
ginning motor  improvement  in  2  cases,  and  improvement  in 
the  electrical  reaction  in  2,  though  paralysis  is  still  com- 
plete. The  time  is  too  short  to  judge  of  the  other  cases.  In 
5  cases  the  gap  was  bridged  with  flaps  from  the  peripheral 
end  of  the  wounded  nerves.  In  1  case  there  was  only 
slight  improvement.  In  4  cases  the  fibers  Avere  separated 
and  the  injured  ones  sutured,  with  2  positive  and  2  negative 
results.  In  one  case  the  peripheral  end  of  the  injured 
peroneal  was  implanted  into  the  tibial  which  was  also  para- 
lyzed from  pressure  by  cicatricial  tissue.  There  was  no 
recovery  of  the  motor  power  of  the  peroneal,  though  sensa- 
tion was  restored ;  the  tibial  recovered  after  neurolysis. 

In  general  Thoele  believes  that  when  there  is  motor 
paralysis  with  partial  reaction  of  degeneration  it  is  best  to 
wait  six  to  eight  weeks  after  the  wound  is  healed  in  the 
hope  that  motility  will  be  restored.  In  complete  motor 
paralysis  and  complete  reaction  of  degeneration  operation 
should  be  performed  as  early  as  possible.  Of  course  this 
may  mean  a  delay  of  some  Aveeks  for  the  Avound  to  heal, 
especially  if  there  is  suppuration.  By  early  operation  he 
means  only  as  early  as  possible  under  aseptic  conditions. 
This  may  mean  from  three  weeks  to  three  months  after  the 
injury.  In  partial  paralysis  with  partial  or  complete  reac- 
tion of  degeneration  it  is  best  to  wait  6  to  8  Aveeks  after  the 
healing  of  the  Avound.  Operation  should  be  performed  as 
soon  as  possible  in  cases  Avhere  there  is  extreme  pain. 


FOREIGN    WAR    LITERATURE.  343 

O'peration  should  he  done  under  general  anesthesia. 
There  is  apt  to  be  secondary  hemorrhage  after  local  anes- 
thesia, and  moreover,  the  electrical  reaction  of  the  nerve 
can  not  be  tested  during  the  operation  if  it  is  infiltrated 
with  novocaine.  He  prefers  not  to  cut  off  the  circulation 
with  the  Esmarch  bandage,  because  when  it  is  applied  vessels 
are  overlooked,  which  cause  secondary  hemorrhage  and  lead 
to  the  formation  of  scar  tis^iue  again.  The  incision  should 
be  made  in  such  a  way  that  the  skin  sutures  do  not  come 
over  the  nerve  sutures.  If  this  can  not  be  avoided  a  flap 
of  fat  or  muscle  should  be  interposed  over  the  nerve.  Many 
surgeons  make  a  sheath  of  fascia  around  the  nerve,  and 
various  other  substances  have  been  proposed  for  these 
sheaths,  such  as  calves'  arteries,  pieces  of  vein,  rubber  tubes, 
etc.  Thoele  believes  that  these  sheaths  contract  and  cause 
adhesions  and  strangulations  of  the  nerve,  so  he  thinks  it 
is  better  to  use  only  a  flat  flap  of  muscle  or  fat,  not  inclosing 
the  nerve  in  a  sheatli.  The  different  bundles  of  the  nerve 
have  different  functions,  so  it  is  important  to  bring  the  cor- 
responding bundles  together  in  suturing.  The  nerve  should 
be  spared  manipulation  as  much  as  possible.  In  seizing  it 
with  forceps  only  the  nerve  sheath  should  be  grasped,  not 
the  nerve  substance.  When  nerves  have  to  be  held  aside  it 
should  be  done  with  strips  of  gauze,  not  with  instruments. 
The  sutures  should  pass  only  through  the  epineurium.  The 
stumps  must  be  brought  together  without  tension.  Three 
or  four  button  sutures  are  enough.  Better  adaptation  is  ob- 
tained with  these  than  with  a  circular  suture  of  the  sheath. 
It  is  well  to  flood  the  nerve  after  suture  with  a  0.5  per  cent 
novocaine-suprarenin  solution.  The  limb  should  be  placed 
in  the  best  position  to  relieve  the  nerve  from  tension  and  it 
should  be  kept  in  a  plaster  cast  for  three  to  four  weeks. 
When  the  gap  is  too  great  to  admit  of  direct  suture  a  flap 
is  made  from  the  injured  nerve  itself  or  from  another 
sensory  nerve.  Where  the  nerve  is  only  partially  severed 
the  author  does  not  advocate  complete  section  and  suturing, 
Init  dissociation  of  the  nerve  fibers  and  suture  only  of  the 
injured  ones,  leaving  the  uninjured  ones  intact. 

The  after  treatment  consists  of  electrical  treatment  with 
the  galvanic  current,  for  the  faradic  current  has  no  effect; 
mechanical  exercise ;  and  local  baths  of  various  Idnds.  Neu- 
ralgia is  not  always  overcome  by  neurolysis.  Heile  thinks 
that  excision  of  the  perineurium  is  of  value  in  neuralgia.  In 
severe  cases  of  neuralgia  in  mixed  nerves  where  neurolysis 
has  not  been  effective  Thoele  resects  the  sensory  tracts  from 
the  nerve  trunk.  In  purely  sensory  nerves  he  resects  and 
sutures  if  there  is  scar  tissue,  oi*  resects  a  piece  of  the  nerve 
and  bridges  the  gap  with  a  flap  from  the  peripheral  stump. 


344  WAR  SUEGEEY   OF   THE   NERVOUS   SYSTEM. 

Wilms:  Early  Operation,  Mechanics  of  Nerve  Injuries  and  Tech- 
nique of  Suture  (Zur  Fnieli-operatiou.  Mec-lianik  tier  Nerven- 
verletzuug  unci  Teehnik  der  Nalit).  Deutsche  med.  Wchnschr., 
1915,  xli,  1417. 

Within  the  first  10  days  to  2  weeks  after  an  injury  it  is 
very  easy  to  suture  the  divided  ends  of  the  nerve,  and  if  some 
of  the  nerve  fibers  are  intact  to  distinguish  them  from  the  in- 
jured ones  and  preserve  them. 

Tlie  conditions  are  ver}?^  different  in  late  operations,  A 
large  amount  of  scar  tissue  has  formed  between  the  ends  of 
the  nerve  which  must  be  removed,  and  a  gap  is  thus  left 
which  requires  great  tension  on  the  nerve  to  fill.  The  limb 
must  be  fixed  for  a  long  time  in  the  position  that  removes 
tension  from  the  nerve.  Moreover  bits  of  bone  have  fre- 
quently become  incorporated  in  the  scar  tissue  which  could 
have  been  very  easily  removed  at  early  operation. 

The  objection  is  vi^ged  against  early  operation  in  all  cases 
that  it  is  iTnpossible  to  tell  whether  operation  is  necessary  or 
not.  Wihns  proposes  in  all  cases  to  make  an  exploratory  in- 
cision to  find  out.  This  can  readily  be  done  under  local 
anaesthesia,  does  no  harm  if  unnecessary,  and  gives  the  pa- 
tient much  better  chances  for  restoration  of  function  if  oper- 
ation is  necessary.  The  nerve  fibers  are  generally  displaced 
in  the  direction  of  the  exit  wound  so  that  spontaneous  restora- 
tion of  function  is  improbable.  To  strengthen  the  suture  it  is 
well  to  leave  a  band  of  tissue  from  the  external  wall  of  the 
neuroma  connecting  the  two  ends  of  the  severed  nerve.  Il- 
lustrations are  given  of  how  this  is  done.  The  sutured  ends 
may  also  be  enveloped  in  sheaths  made  of  calves'  arteries, 
fascia,  or  other  material. 


Delorme:  Injuries  of  Nerves  by  Projectiles,  Especially  Injuries  of 
the  Sciatic  (Sur  les  blessiires  des  uerfs  par  les  projectiles  et  en 
particulier  sur  les  blessures  de  sciatique).  Rev.  de  clnr.,  1915. 
xxxiv,  402. 

Delorme  discussed  the  above  subject  before  the  Paris  Sur- 
gical Society,  basing  his  conclusions  on  a  large  number  of 
cases  that  he  had  had  occasion  to  operate  upon.  He  is  an 
advocate  of  operation  after  cicatrization  of  the  wound,  espe- 
cially in  cases  where  paralysis  begins  at  once  and  does  not 
show  improvement.  When  the  incision  is  made  the  ends  are 
generally  found  several  centimeters  from  each  other,  a  large 
neuroma  occupying  the  intervening  space.  In  these  cases  he 
sections  the  nerve  beyond  the  neuroma,  brings  the  ends  to- 
gether and  sutures  them.  In  some  eases  there  is  cicatricial 
adhesion  of  the  nerve  to  neighboring  parts,  but  no  break  in 
the  continuity  of  the  nerve. 

He  explores  carefully  till  he  finds  the  limits  of  the  lesion, 
excises  the  cicatricial  tissue  and  sutures  the  freshened  ends 
of  the  nerve  together.  In  some  cases  of  contusion  of  the 
sciatic  that  give  rise  to  persistent  pain,  localized  adhesions 
are  found,  but  sometimes,  even  when  the  pain  is  intense,  no 
visible  lesion  can  be  discovered. 


FOREIGN    WAR  LITERATURE.  345 

In  the  discussion  Gosset  said  that  he  had  performed  CO  op- 
erations for  wounds  of  the  peripheral  nerves.  He  believes 
that  every  time  an  injury  of  a  peripheral  nerve  is  diagnosed 
an  exploratory  incision  should  be  made,  so  that  the  lesion  can 
be  observed  directly.  This  exploratory  incision  should  be 
made  within  two  or  three  weeks  after  the  injury. 

Routier  expressed  surprise  at  the  number  of  operations 
performed  by  Delorme,  and  at  the  fact  that  he  applied  the 
same  treatment  to  all  cases.  He  has  only  operated  in  three 
cases. 

Legueu  pointed  out  that  there  are  two  objections  to  early 
operation  in  nerve  injuries:  Persistent  suppuration  and  the 
difficulty  of  making  an  exact  diagnosis  of  the  nerve  lesion. 
He  advocates  exploratory  incision. 

Delbet  expressed  surprise  at  the  large  number  of  opera- 
tions performed  by  Delorme,  and  at  the  fact  that  he  seemed 
to  have  sacrificed  the  nerve  trunk  without  having  any  exact 
information  as  to  its  anatomical  condition  or  its  phj^siological 
value. 

Quenu  declared  that  it  was  impossible  to  recognize  with 
the  naked  eye  whether  the  nerve  was  intact  and  to  detemijne 
the  anatomical  value  of  a  nerve  cicatrix. 


Hezel,  O.:  Injuries  of  Peripheral  Nerves  During  War  ( Kriessver- 
letzvingen  cles  peripiierisclien  Nervensystems ) .  Med.  Klin.,  Beii., 
1914.  No.  45,  1663. 

From  the  experience  derived  during  the  last  wars,  it  is 
evident  that  1  to  2  per  cent  of  all  injuries  are  compli- 
cated by  injuries  of  or  damage  to  peripheral  nerves.  The 
peripheral  nerves  may  be  injured  by  gunshot  wounds,  stab 
wounds,  crushing  injuries,  and  by  infectious  toxins.  In- 
fectious neuritides  arise  from  infected  wounds.  Most  fre- 
quent injuries  are  the  gunshot  injuries,  which  may  be  di- 
rect and  indirect.  Not  only  the  nerves  struck  directly  by 
the  bullet  are  injured,  but  others  more  distant  from  the 
bullet  canal.  A  distant  action  still  unexplained  takes 
place  here.  The  symptoms  of  the  distantly  injured  nerves 
retrogress  in  time,  whereas  those  symptoms  due  to  direct 
injury  of  the  nerve  are  more  or  less  permanent  unless 
operative  measures  are  instituted  and  the  nerve  sutured. 
Examination  does  not  reveal  whether  in  a  groin  case  of 
nerve  injury  a  complete  severance  of  the  continuit}^  of  the 
nerve  or  only  a  complete  functional  inhibition  with  a  re- 
tained continuity  exists. 

In  cases  of  nerve  injury  by  blunt  force  without  a  pene- 
trating wound,  even  in  the  presence  of  complete  func- 
tional inhibition,  a  restoration  of  function  is  much  more 
probable  than  in  injuries  by  bullets.  Operative  inter- 
ference is  not  at  all  considered  in  such  cases.  In  stab 
wound  injuries  of  peripheral  nerves,  it  is  possible  only  in  the 
rarest  of  cases  to  obtain  functional  conduction  Avithout  sur- 
gical   interference.     As    a    rule   Hezel    recommends    that 


346  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

operations  on  the  nerves  be  performed  as  soon  as  the 
necessity  of  such  an  operation  is  apparent,  provided  the 
wound  conditions  permit.  Not  only  motor  disturbances, 
but  also  neuralgias  at  times  are  indications  for  surgical 
interference. 


Edinger,  L.:  The  Uniting  of  Divided  Nerves  (Ueber  die  veieiniguiig 
getremiter  Nerven.  Grundsaetzliches  imd  Mitteiliuig  eines  neiien 
verfalirens).    Mucuchen  vteil.  Wchnschr.,  1916,  Ixiii,  225. 

Edinger  has  found  that  there  is  often  great  difficulty 
in  the  union  of  the  ends  of  severed  nerves.  The  regener- 
ated nerve-fibers  which  are  thrown  out  by  the  ganglion 
cells  can  easily  be  diverted  from  their  course  by  any  me- 
chanical obstruction,  such  as  a  blood  clot,  and  union  be- 
tween the  stumps  can  therefore  be  prevented.  He  shows 
that  this  is  the  case  by  his  own  observation  and  those  of 
others  whom  he  quotes. 

The  only  way  that  the  regenerated  fibers  may  he  I'ept  in 
the  proper  direction  to  effect  union  is  to  permit  them  to 
grow  in  a  tube.  Nevertheless  the  attempts  made  to  grow 
nerve  fibers  in  tubes  by  previous  workers  did  not  give 
good  results  because  it  was  necessary  for  the  fibers  to  be 
surrounded  in  the  tube  by  a  suitable  environment  for 
growth.  The  various  experiments  of  Edinger  demon- 
strated that  human  nerve  fibers  grow  best  when  the  two 
disunited  ends  are  inserted  in  an  artery  filled  ivith  agar 
jelly.  This  is  the  new  procedure  which  he  advocates.  A 
number  of  such  tubes  have  been  prepared  and  distributed 
for  use  to  operating  neurologists. 

Edinger  has  seen  the  results  obtained  by  Ludlofi'  and 
Hasslauer  with  14  patients  treated  in  this  manner,  in 
which  cases  the  distance  between  the  disunited  nerve  ends 
varied  from  5  to  15  cm.  In  every  case  there  Avas  clear 
evidence  of  good  progress  of  regeneration  in  the  nerve. 
Within  a  few  weeks  the  anaesthesia  area  became  much  re- 
duced. He  mentions  particularly  a  case  in  which  10  cm. 
of  the  tibial  and  8  cm.  of  the  popliteal  nerve  had  been  re- 
sected. After  inserting  the  agar  jelly  tube  the-  return  of 
the  plantar  reflexes  was  demonstrable  after  16  days. 


Borchardt,    M.:    Gunshot    Injuries    of    Peripheral    Nerves    i  S(lui!>s- 

verletzangeii    peripherev    Nerven).      Bcltr.    .;.    Idin.    Vh'tr..    lOl.j. 
xcvii,  'J.i\?>. 

As  consulting  surgeon  of  the  third  army  corps  and  sur- 
geon of  the  military  prisoners  at  Zossen,  Borchardt  has  seen 
several  hundred  cases  of  nerve  injury,  and  has  operated  upon 
more  than  70.  In  this  article  he  gives  the  history  of  56  cases. 
Of  the  series,  17  were  injuries  of  the  radial,  8  of  the  median, 
7  of  the  ulnar,  7  of  the  ulnar  and  median.  1  of  the  musculo- 
cutaneous, 8  of  the  brachial,  cervical,  or  lumbar  plexus.  8  of 
the  sciatic.  Excellent  plates  are  given,  containing  :>1)  illus- 
trations showing  the  operations. 


FOBEIGN   WAR   LITERATURE.  347 

The  indications  for  operation  were  decided  upon  accord- 
ing to  the  principles  laid  down  by  Oppenheim,  Cassirer, 
and  other  noted  neurologists.  Operation  ivafi  performed 
tvhen  the  neurological  findings  indicated  that  there  was 
severe  injury  of  the  nerve,  either  from  partial  on  total  sec- 
tion of  the  nerve  or  from  scar  forvvition  around  it.  He 
operated  if  there  vxis  complete  motor  paralysis,  complete 
reaction  of  degeneration,  or  seoere  disturhances  of  sensation. 
Operating  on  these  indications,  he  met  with  negative  find- 
ings on  operation  in  only  2  cases.  Among  the  56  cases,  in 
IS  the  nerves  were  found  completely  and  in  1  partially  sev- 
ered. The  stumps  were  generally  swollen,  with  club-shaped 
ends.  In  the  other  cases  there  were  more  or  less  extensive 
scars,  and  sometimes  foreign  bodies  were  embedded  in  the 
nerves,  such  as  bits  of  metal  or  cloth,  fragments  of  bone  or 
nuiscle  fibers. 

In  operation  the  greatest  care  was  taken  to  control  hem- 
orrhage, so  as  to  avoid  the  formation  of  eren  the  smallest 
hamatomata,  which  might  lead  to  renewed  scar  formation. 
If  the  tissue  around  the  nerve  showed  cicatricial  changes,  a 
sheath  of  fat  or  soft  fascia  was  put  around  the  nerve.  The 
chief  factors  in  the  early  restoration  of  function  are  care- 
ful suture,  absolute  asepsis  in  operation,  the  avoidance  of 
htematomata  and  early  movement,  massage,  and  electrical 
treatment. 

Direct  suture  is'fo  he  preferred  to  all  other  methods.  Care 
must  he  taken  in  suturing  to  hring  the  corresponding  nerve 
tracts ^  into  exact  apposition.  The  muscles  should  be  spared 
all  injury  so  far  as  possible.  If  palpation  or  exploratory  in- 
cision shows  cicatricial  tissue,  it  should  be  excised. '  Of 
course,  the  ideal  procedure  would  l^e  to  excise  into  sound 
nerve  tissue,  but  the  histological  examination  of  apparently 
normal  cross  sections  of  nerves  gave  surprising  results.  The 
plates  show  some  histological  pictures  of  cross  section  of 
nerves  were  apparently  normal,  but  the  microscope  reveals 
the  fact  that  they  contain  considerable  cicatricial  tissue, 
and  in  some  places  there  are  no  nerve  fibers  left  at  all,  or  else 
they  are  only  tubes  of  nerve  tissue  filled  with  scar  tissue. 
But  Borchardt  believes,  as  does  Cassirer.  that  it  is  better  to 
suture  such  nerves,  even  though  they  contain  some  scar 
tissue,  than  to  remove  such  large  pieces  that  they  can  not  be 
sutured  together.  If  only  a  part  of  the  nerve  is  injured,  elec- 
trical examination  will  show  what  part  of  it  should  be 
resected. 

Borchardt  recorximends  that  operation  be  done  as  early  as 
possible,  because  it  is  technically  easier  then  and  because 
early  operation  prevents  contractures  of  the  muscles  and 
joints  and  trophic  disturbances.  In  the  author's  own  cases 
the  time  between  the  injury  and  the  operation  varied  from 
two  weeks  to  nine  months.'  In  6  cases  there  were  also  in- 
juries of  the  vessels,  but  the  vessel  wounds  closed  spontane- 
ously, without  the  formation  of  aneurisms.  Among  the  56 
cases,  25  were  under  obser\ation  longer  than  three  months; 
21  of  tliese  were  improved  and  4  not  improved.    The  results 


348  WAE   SURGERY   OF   THE    NERVOUS   SYSTEM. 

were  particularly  good  in  3  cases  of  nerve  suture,  function 
being  completely  restored.  Borchardt  believes  that  the  re- 
sults of  oferation  have  heen  given  more  praise  than  tliey 
deserved. 


Heinemann,  O.:  Gunshot  Injuries  of  the  Peripheral  Nerves;  An- 
atomic Investigation  of  the  Inner  Structure  of  the  Great  Nerve 
Trunks  ( Ueber  Sctiussverletzungen  der  peripheren  Nerven ; 
ana  torn  isclien  Uutersuchungen  ueber  den  innereu  Bau  der  grossen 
Nerveustaenuue).    Arch.  f.  kliii.  Chir.,  1916,  cviii,  107. 

Heinemann  finds  that  nerve  suture  has  in  general  given 
70  to  80  per  cent  positive  results.  In  his  own  eases  he  ob- 
tained 75  per  cent  good  results. 

Although  Stoffel  has  condemned  nerve  transplantations, 
yet  by  this  means  Gratyl  obtained  66  per  cent  successes  in 
nerve  defects.  The  prognosis  of  gunshot  injuries  of  the 
nerves  is  in  Heinemann's  experience  good.  Previous  to  the 
war  it  was  known  that  the  reconstitution  of  nerve  function- 
ing took  a  very  long  time.  It  takes  about  two  years  before 
it  can  be  stated  with  certainty  that  there  is  no  return  of 
nerve  functioning.  Heinemann's  optimism  is  based  upon 
his  observations  of  recovery  in  apparently  noncurable  cases. 
There  were  only  two  cases  of  nerve  suture  in  which  positive 
results  were  not  obtained  and  these  are  still  under  observa- 
tion. 

The  most  striking  successes  are  obtained  in  neurolysis. 
Paralysis  may  disappear  within  24  hours;  whereas  after 
resection  such  a  result  is  not  usually  obtained  till  after  two 
months. 

For  the  aftertreatment  of  nerve  injuries  Heinemann  ad- 
vocates electricity.  Systematic  electrical  treatment  greatly 
facilitates  recover3^  This  is  particularly  the  case  in  pa- 
tients with  weak  will  power. 


Tuffier,   T.:   Treatment   of  Injuries   of  the   Nerves   by    Projectiles 

(Traitement   des   lesions   des   nerfs   par   projectiles   de   guerre). 
Bull,  et  lueni.  >Sof.  <lc  chir.  de  Par.,  1915.  xli,  1911. 

Tuffier  reported  the  work  of  Dumas  on  280  cases  of  nerve 
lesions  during  the  war.  From  his  results  he  concludes  that 
section  and  suture  of  the  nerves  should  be  practiced  only 
when  no  other  treatment  is  possible.  Among  his  280  cases, 
nerve  suture  was  practiced  in  only  19 .^  and  in  none  of  these 
cases  was  motion  restored'. 

The  treatment  of  choice  is  to  liberate  the  nerve  from  scar 
tissue  and  make  a  sheath  for  it  of  some  substance  that  will 
protect  it  from  further  cicatrization.  The  nerve  should  be 
handled  as  little  and  as  gently  as  possible,  and  the  cicatricial 
tissue  developed  within  the  nerve  itself  should  not  be 
touched.  Even  where  the  nerve  has  been  completely  sev- 
ered the  conservative  method  is  still  indicated. 

Dumas  reports  a  case  to  illustrate  his  method  of  leaving  a 
bridge  of  sclerotic  tissue  about  the  size  and  shape  of  the  nerve 
between  the   severed   ends.     Gradually   nerve  fibers   grow 


FOREIGN"   WAR   LITERATURE,  349 

through  this  from  the  distal  to  the  peripheral  end  and  func- 
tion is  restored.  After  the  nerve  is  freed  it  must  he  pro- 
tected, and  he  finds  that  the  hest  material  for  this  purpose  is 
fatty  tissue.  This  may  be  taken  from  the  patient  himself  or 
from  some  one  else.  Its  softness  and  elasticity  make  it  an 
ideal  material  for  protecting  the  nerve  from  compression  by 
neAv-formed  scar  tissue.  Other  materials  frequently  used, 
such  as  hernial  sac,  veins,  and  aponeurosis,  are  not  thick 
enough  to  give  as  efficient  protection. 

He  has  found  this  method  ]Darticularly  effective  in  those 
very  painful  lesions  of  the  median  nerve  which  many  oper- 
ators reported  as  helpless. 

Lyle,  H.  M.  M.:  The  Physiological  Treatment  of  Bullet  and  Shell 
Wounds  of  the  Peripheral  Nerve  Trunks.  *S' (////.  (///».  and  Ohst.. 
1916,  xxii,  127. 

Lyle,  from  his  experience  in  the  war  zone,  draws  the  fol- 
lowing conclusions: 

1.  Damage  to  an  important  peripheral  nerve  is  an  injury 
of  extreme  gravit3^ 

2.  Primary  nerve  suture  is  rarely  indicated. 

3.  Unrelieved,  overstretched  muscular  tissue  leads  to  fatty 
degeneration  and  loss  of  contractility. 

4.  A  paralytic  deformity  with  shortened  muscle  and  lim- 
ited joint  movement,  in  the  majority  of  cases,  is  the  result 
of  ignorance  or  neglect. 

5.  It  is  imperative,  whether  the  nerve  is  divided  or  not, 
that  the  paralyzed  muscles  be  relaxed  and  protected  from 
strain  by  a  suitable  apparatus.  Under  no  circumstances 
must  this  be  deferred  to  the  so-called  after  treatment.  The 
postural  prophylaxis  begins  with  the  reception  of  the  wound, 
and  continues  after  the  operation  until  voluntary  motion  is 
restored.  A  strict  adherence  to  this  vital  orthopedic  prin- 
ciple aids  in  the  diagnosis,  hastens  recovery,  prevents  many 
distressing  deformities,  and  will  materially  diminish  the 
number  of  useless  limbs. 


Marburg,  O.,  and  Ranzi,  E.:  Gunshot  Injuries  of  Peripheral  Nerves 

(Zur    Frage    der    Schussverletziingen    der    peripheren    Nerven). 
Wein.  klin.  Wchnsclir.,  1915,  xxviii,  611. 

From  experience  with  2  nonoperative  and  48  operative 
cases  of  nerve  injuries  the  authors  come  to  the  following 
conclusions : 

1.  When  after  a  gunshot  injury  there  is  loss  of  motion  and 
sensation  and  complete  lack  of  electrical  reaction,  operation 
is  indicated  as  soon  as  the  wound  has  healed. 

2.  When  there  is  loss  of  motion  and  sensation  and  the  elec- 
trical reaction  is  growing  worse,  operation  is  indicated. 

3.  When  there  is  loss  of  sensation  and  motion,  with  no 
tendency  to  improvement,  and  the  reaction  of  deg'eneration 
remains  stationary  for  several  weeks,  operation  is  indicated. 

4.  If  there  are  suppurating  wounds,  operation  should  be 
delayed  for  several  weeks. 


350  WAE    SUEGERY   OF   THE   NERVOUS  SYSTEM. 

Stoney,  R.  T.:  Nerve-Suture  for  Bullet  Wounds.    Brit.  M.  .].,  1915, 
ii,  10. 

As  an  operating  surgeon  in  the  French  Army  the  author 
had  many  opportunities  of  seeing  cases  of  lierve  injury 
caused  by  modern  weapons.  From  four  operated  cases  he 
concludes  as  follows : 

1.  The  function  of  a  nerve  may  be  interrupted  without 
material  injury,  in  which  case  the  loss  of  function  is  only 
partial  and  returns  early,  probably  within  a  fortnight  or 
three  weeks. 

2.  When  a  nerve  is  partially  or  wholly  divided  loss  of 
function  is  marked  and  permanent  and  may  even  lead  to 
increase.  In  these  cases  it  is  useless  to  expect  spontaneous 
regeneration,  owing  to  the  distortion  and  separation  of  the 
cut  ends  and  the  great  development  of  dense  fibrous  tissue, 
which  appears  to  follow  in  all  cases. 

3.  When  a  nerve  is  divided,  the  sooner  an  operation  for  its 
suture  is  performed  the  easier  it  is  and  the  greater  the  likeli- 
hood of  an  early  cure.  In  cases,  however,  where  the  wound 
is  septic,  it  maj^  be  advisable  to  allow  time  for  the  wound  to 
heal. 

4.  Even  when  no  treatment  has  been  given  for  several 
months  there  is  still  a  chance  of  a  successful  result  if  late 
suturing  is  undertaken,  so  that  no  case  need  be  looked  upon 
as  necessarily  hopeless. 


Auerbach,  S.:  Treatment  of  Gunshot  Injuries  of  Peripheral  Nerves 

(Znr  Bebandluiis  der  Scliussverletzuugen  pei'ii)lierisclien  Xerven). 
Deutsche  mcd.  Wchnschr..  191.">,  xli,  2.54. 

There  is  a  gi'eat  deal  of  difference  of  opinion  as  to  whether 
gunshot  injuries  of  the  peripheral  nerves  should  be  treated 
operatively  or  conservatively  and  as  to  how  long  electrical 
and  mechanical  treatment  should  be  continued  before  opera- 
tion ]s  undertaken.  From  his  experience  thus  far  Auerbach 
is  inclined  to  adopt  the  following  rules : 

1.  Those  cases  are  to  be  treated  conservatively  in  which 
the  motor  and  sensory  disturbances  are  slight  and  in  which 
electrical  examination  reveals  only  a  slight  decrease  in  elec- 
trical excitability  or  a  partial  reaction  of  degeneration.  In 
such  cases  there  is  an  imi^rovement  in  function  in  three  or 
four  weeks,  although  complete  recovery  may  take  eight 
weeks  or  even  three  months. 

2.  Those  cases  should  be  operated  on  in  which  there  is' 
complete  motor  paralj^sis  and  complete  reaction  of  degener- 
ation. As  soon  as  the  wound  is  healed  the  nerve  should  be 
laid  bare  and  its  condition  determined  and  the  operative 
indications  decided  upon.  Neurolysis  may  be  performed, 
embedding  the  nerve  in  sound  muscle  tissue,  or  the  nerve 
may  be  inclosed  in  tubes  of  various  materials,  or  if  the  nerve 
trunk  is  completely  severed  nerve  suture  may  be  done.  If 
there  is  extensive  loss  of  substance  of  the  injured  nerve,  one 
of  the  various  plastic  operations  on  nerves  may  be  per- 
formed.   If  there  is  a  neuroma,  the  nerve  should  be  resected 


FOREIGN    WAR    LITERATURE,  351 

into  sound  tissue  iind  a  plastic  operation  performed.  If 
there  are  callous  changes,  such  segments  of  the  nerve  should 
he  resected. 

3.  It  is  more  diificult  to  decide  on  treatment  in  the  transi- 
tion cases  l)etw'3en  the  first  and  second  group,  but  Auerhach 
is  inclined  in  douhtful  cases  to  adinse  e.jcposlng  the  nerve. 
as  it  is  not  a  dangerous  procedure.  If  conservative  treatment 
is  preferred,  he  Avould  advise  that  if  there  is  no  functional 
improA'^ement  in  six  or  eight  weeks  operation  should  then  l)e 
performed. 

4.  Operation  is  also  indicated  in  cases  in  which  there  is 
severe  and  long-continued  pain.  This  complication  is  quite 
frequent.  Of  course,  operative  treatment  in  all  cases  must 
be  followed  by  S3^stematic  electrical  and  mechanical  treat- 


Cassirer,  R. :  Operative  Treatment  of  Injuries  of  the  Peripheral 
Nerves  in  War  (Die  operative  Behandluiij;'  i\ev  Krie.sisverletzung- 
en  der  periplierisolieii  Nervenl.  DciilscJic  iiinl.  Wclihsdir..  191.5, 
xli.  .")20. 

Cassirer  gives  histories  of  three  cases.  The  first  was 
paral^^sis  of  the  radial  from  a  fragment  of  a  shell.  Oper- 
ation was  performed  two  weeks  after  the  injury:  the  nerve, 
which  had  been  severed,  was  sutured.  Three  and  one-half 
months  after  operation  there  were  signs  of  returning  motil- 
ity, which  slowly  but  steadily  progressed.  The  second  had 
paralysis  of  the  deep  branch  of  the  radial.  Four  Aveeks 
later  the  nerve,  w- hich  Avas  completely  severed,  was  sutured ; 
eight  Aveeks  after  the  operation  there  Avas  movement  in  the 
paralyzed  region,  Avhich  increased  rapidly  in  strength  and 
extent.  The  third  case  Avas  a  filicture  of  the  humerus,  Avith 
injury  of  the  radial,  follow^ed  immediately  by  paralysis. 
Operation  Avas  performed  three  months  later,  consisting  of 
neurolysis  and  extirpation  of  a  piece  of  bone  from  the  nerve. 
After  six  weeks  improvement  began. 

The  author  has  seen  about  240  cases  of  nerve  injury,  in 
60  of  which  operation  Avas  indicated.  In  OA^er  25  per  cent 
of  these  the  nerve  was  completely  severed :  in  the  other  180 
neurological  examination  shoAved  that  operation  was  not 
indicated.  There  Avas  no  reaction  of  degeneration  and  motor 
and  sensory  functions  Avere  preserved.  Expectant  treatment 
is  generally  advocated  in  nerve  injuries,  but  Cassirer  thinks 
that  in  all  cases  where  neurological  examination  indicates 
operation  it  should  be  performed  promptly  as  soon  as  the 
Avound  is  healed.  He  thinks  the  advantages  of  early  opera- 
tion far  outAveigh  its  dangers. 


Chiray,  M.,  and  Roger,  E.:  Nerve  Sutures  (Des  sutures  nerveuses). 
Bull,  et  ni4m.  Soc.  m6cL.  d.  Ii6p.  de  Par.,  1916,  xl,  2149. 

The  authors  in  a  long  and  exhaustiA^e  article  point  out  that 
there  is  need  for  unanimity  among  neui-ologists  regarding 
the  classification  of  cases  to  be  included  in  statistics  of  nerve 
suture;  also  as  regards  the  criteria  of  restoration.     They 


352  WAR   SURGERY   OF   THE    NERVOUS   SYSTEM. 

define  four  classes  of  motor  restoration:  (1)  Lesions  with 
no  motor  restoration;  (2)  lesions  with  slight  motor  restora- 
tion; (3)  lesions  with  advanced  motor  restoration;  (4) 
lesions  with  complete  motor  restoration.  The  third  class 
includes  a  return  of  voluntary  motility  sufficient  for  the  exe- 
cution of  movements  of  the  paralyzed  muscle  with  the  am- 
plitude but  without  the  normal  strength.  The  fourth  class 
includes  complete  restoration  of  amplitude  and  motor  force. 
From  their  extensive  investigations  into  the  results  of 
nerve  suturing  the  authors  conclude : 

1.  Cases  for  suture  should  be  selected  with  care  and  suture 
confined  to  cases  of  total  and  complete  section  of  the  nerve. 
As  regards  restorations,  it  is  necessary  to  know  what  errors 
can  arise  in  observation,  as  thereby  false  conclusions  may  be 
reached  regarding  motor  or  electrical  restoration. 

2.  From  chronological  reports  of  the  different  stages  of 
electrical  and  motor  restorations,  the  authors  find  that  the 
first  always  precedes.  The  beginning  of  the  reappearance 
of  movement  is,  according,  to  their  experience,  in  about  five 
months  for  the  radial,  eight  months  for  the  cubital,  seven 
months  for  the  median,  two  to  five  months  for  the  popliteal 
sciatic.  The  radial  and  popliteal  sciatic  nerves  give  the  best 
results. 

3.  According  to  the  authors'  experience  the  result  is  the 
more  favorable  according  as  intervention  is  earl3^  But  even 
so,  operations  done  from  the  fourth  to  the  sixth  month  after 
injury  give  a  large  proportion  of  successful  results. 

The  important  points  in  every  intervention  are  the  total 
resection  of  all  fibrous  tissue,  the  necessity  of  coapting  with- 
out torsion,  without  dragging,  and  without  crushing  the 
nerve.  End-to-end  suture  and  grafting  give  equally  good 
results. 

4:.  The  authors  are  convinced  of  the  importance  of  post- 
operative care,  particularly  of  the  functional  prosthesis  and 
ionization  with  iodide  of  potassium  about  the  operative 
cicatrix  and  the  nerve  suture. 


Heile  and  Hezel:  Experiences  in  the  Treatment  of  Peripheral 
Nerves  Wounded  in  War  ( Unsere  bisherigen  Erfahrnngeu  bei 
(ler  Behandlung  im  Kriege  veiietzter  peripberer  Nerveii).  Beitr. 
^.  klin.  CMr.,  1915,  xcvi,  299. 

The  scarcity  of  dependable  data  concerning  the  handling 
of  wounds  of  peripheral  nerves  in  previous  wars  and  the  ex- 
traordinary number  of  cases  which  have  presented  them- 
selves in  this  war  have  led  Heile  and  Hezel  to  report  in 
detail  the  neurologic  findings  and  operative  procedures  of 
40  cases.  It  is  their  intention  to  report  later  concerning  the 
results  obtained. 

Heile  discusses  the  surgical  procedures.  He  considers  op- 
erative interference  desirable  if  no  improvement  has  oc- 
curred in  from  four  to  six  Aveeks  after  the  injury  was  sus- 
tained. A  general  anesthetic  is  to  be  preferred,  not  onlj'^ 
because  such  operations  require  a  long  time,  but  because  the 


FOREIGN    WAR   LITERATURE.  353 

hemorrhage  wliich  supervenes  after  a  h)cal  anesthetic  is  likely 
to  interfere  with  the  growth  of  the  sutured  nerves. 

In  the  majority  of  cases  the  nerve  trunk  is  not  completely 
severed.  It  is  of  great  importance  to  avoid  injuring  such 
unbroken  fibers  whenever  possible.  An  attempt  was  made 
in  some  cases  to  search  out  the  corresponding  bundles  in  the 
proximal  and  distal  ends  and  to  suture  them,  but  the  diffi- 
culties were  very  great.  Much  time  and  care  is  required  to 
dissect  the  nerve  trunk  out  of  the  scar  tissue  in  which  it  is 
usually  embedded.  This  may  be  facilitated  by  Ijeginning  at 
either  side  of  the  scar  and  loosening  the  nerve  for  a  short 
distance  in  the  healthy  tissue,  holding  it  up  by  thin  strips  of 
gauze  and  by  gentle  traction,  putting  the  adherent  portions 
on  the  stretch.  The  nerve  sheath  is  then  split  and  loc-'sened 
from  the  nerve  trunk.  In  the  healthy  portion  tliis  is  easily 
accomplished  with  a  blunt  instrument,  a  small  elevator,  or 
strabismus  hook.  By  the  injection  of  air  or  salt  solution  the 
sheath  is  ballooned  out  and  loosened  from  the  trunk.  Over 
the  injured  portion  the  perineurium  may  be  markedlj^  thick- 
ened and  pressing  on  the  nerve.  In  such  a  case  a  sharp  in- 
strument is  required  to  loosen  it.  If  neighboring  bones  are 
broken,  there  may  be  splinters  of  bone  in  the  scar  or  even  in 
the  nerve,  or  the  callus  or  bom^  spines  may  be  pressing  on  the 
nerve.  The  separation  of  the  very  firmly  adherent  blood 
vessels  is  ver}^  difficult  and  often  further  complicated  by  in- 
juries to  the  vessel  walls.  These  aneurismal  enlargements 
often  can  not  be  diagnosed  in  advance  on  account  of  the  in- 
tervening scar  tissue. 

When  the  proportion  of  broken  to  unbroken  bundles  is 
small  it  is  not  so  difficult  to  adapt  the  distal  and  proximal 
ends  of  the  fibers  which  belong  together,  but  when  the  pro- 
portion is  reversed  this  is  frequently  not  possible.  A  little 
help  may  be  obtained  by  laying  the  fibers  in  their  apparent 
anatomical  arrangement  before  suturing.  The  motor  and 
sensor}^  fibers  may  be  distinguished  by  electricity,  but  this 
can  not  always  be  used,  as  in  the  majority  of  cases  the  distal 
portion  can  not  be  stimulated  by  either  the  galvanic  or  the 
faraclic  current,  and  in  others  the  proximal  portion  may  fail 
to  be  stimulated.  Electricity  is,  however,  useful  at  the  be- 
ginning of  operation  in  badly  distorted  cases  to  distinguish 
the  principal  nerve  trunks,  as  the  median  from  the  ulnar, 
etc.  It  is  hopeless  to  try  to  associate  by  this  means  the  cen- 
tral and  peripheral  portions  of  individual  fibers.  Experi- 
ence in  former  wars  seems  to  show  that  such  careful  adapta- 
tion is  not  of  great  importance.  Whenever  the  whole  nerve 
was  severed  or  severely  injured,  the  necessar}^  resection 
was  done  and  the  ends  sutured  in  the  best  way  to  avoid 
stretching  if  possible.  P'or  suture  material  fine  silk  was  used 
at  first ;  latei'  fine  catgut.  Whenever  individual  nerve-fiber 
bundles  remained  intact  they  Avere  used  as  splints  for  the 
sutured  ones.  Unless  tension  made  it  necessary  to  go  deeper 
the  stitches  ha^■e  incliuled  only  the  supporting  substance  of 
the  nerve,  but  it  is  always  necessary  to  see  to  it  that  the  por- 
tions brought  into  contact  consist  of  pure  nerve  substance. 

1.3704—17 23 


354  WAR   SUEGEEY    OF   THE    NERVOUS   SYSTEM. 

Whenever  the  perineurium  was  sufficiently  thickened  to 
press  upon  the  nerve,  it  was  removed  as  a  foreign  body.  It 
was  also  frequently  removed  in  cases  in  which  it  merely 
showed  definite  symptoms  of  inflammation,  and  especially  in 
cases  which  showed  symptoms  of  peripheral  neuritis.  In 
many  cases  the  pain  was  permanently  relieved  in  this  way, 
in  others  it  returned  after  a  while,  but  these  latter  were 
apparently  cases  of  ascending  neuritis.  The  sheath  should, 
in  any  event,  be  split  lengthwise  to  free  the  nerve  bundles  of 
the  inflammatory  exudate  between  them.  Such  an  exudate 
may  result  from  the  suturing  of  the  nerve.  Therefore,  the 
sheath  should  be  split  for  several  centimeters  on  both  sides 
of  the  suture,  and  this  slit  should  not  be  resutured. 

In  cases  requiring  resection  up  to  6  centimeters,  the  cen- 
tral and  peripheral  ends  of  the  nerve  were  dissected  out  of 
the  soft  parts  and  displaced  subcutaneously  as  far  as  possi- 
ble ;  the  distance  was  decreased  by  flexion  or  extension,  and 
finally,  by  fine  spiral  incisions  in  the  perineurium,  the  ends 
were  lengthened  somewhat.  Stay  sutures  along  the  sides  of 
the  nerve  were  used  to  assist  in  holding  the  approximated 
ends  together,  and  if  the  tension  was  great,  these  stitches 
had  to  include  nerve  bundles  to  avoid  tearing  out.  Great 
care  was  exercised  to  see  that  nothing  was  interposed  be- 
tween the  active  nerve  substance  of  the  sutured  ends.  Fi- 
nally, it  is  necessary  to  protect  the  sutured  nerves  from 
pressure,  especially  in  cases  of  bone  fracture.  This  is  best 
accomplished  by  the  interposition  of  a  neighboring  muscle, 
or  a  pedunculated  muscle  flap. 

In  cases  in  which  it  was  necessary  to  use  tubes,  rubber 
tubes,  prepared  from  pure  rubber  and  not  vulcanized,  were 
used.  The  tubing  was  boiled  in  salt  solution  and  split 
lengthwise.  Prepared  in  this  way  it  can  be  used  to  inclose 
the  stumps  of  nerves  or  it  can  be  used  to  protect  the  sutured 
nerve  from  its  surroundings. 

Hezel  describes  the  40  cases  in  detail,  giving  the  point  of 
entrance  and  exit  of  the  bullet,  Avhich  nerves  were  injured 
and  how  badly,  a  description  of  the  findings  upon  operative 
exposure  of  the  part,  and  the  surgical  procedures  applied. 
The  neurologic  examination  included,  with  a  few  excep- 
tions, only  the  motor  functions.  The  injuries  were  classified 
as  severe,  moderate,  and  light.  In  severe  cases,  the  nerves 
were  not  responsive  to  either  the  galvanic  or  faradic  current, 
and  the  muscles  did  not  respond  to  the  faradic  and  but  slug- 
gishly to  the  galvanic.  In  moderate  cases  the  electrical 
irritability  of  the  nerves  was  not  absent,  but  materially  re- 
duced quantitatively,  and  sometimes  altered  qualitatively; 
the  muscles  qualitatively.  Light  cases  showed  at  most  quan- 
titative reduction,  no  qualitative  changes.  The  findings 
upon  exposure  of  the  injured  area  vary  according  to  whether 
or  not  the  nerve  is  completely  severed.  If  it  is  completely 
severed,  both  the  ends  are  usually  embedded  in  dense  scar 
tissue  with  a  space  between  them.  Unless  the  operation  is 
undertaken  very  early,  the  central  stump  will  show  a  swell- 


FOREIGN    WAR    LITERATURE.  355 

ing  consisting  of  a  neuroma.  Otherwise  the  severed  nerves 
are  not  much  enhirged,  and  the  peripheral  portion  may  even 
be  somewhat  atrophied.  If  the  nerve  is  not  broken,  but 
merely  grazed  or  crushed  by  the  shot,  there  will  be  an  irreg- 
ular swelling  of  several  centimeteis  length  distal  to  the  point 
of  injury.  This  is  doubtless  caused  by  inflammatory  exudate 
inside  the  nerve-sheath  with  consequent  obstruction  of  the 
venules  and  lymphatics  of  the  nerve.  This  swelling,  which 
may  be  twice  or  even  three  times  the  diameter  of  the  nerve, 
is  gradually  reduced,  nnd  induration  of  the  nerve-sheath 
and  interstitial  tissue  takes  the  place  of  the  infiltration.  In 
cases  in  which  the  nerve  is  penetrated  by  the  shot,  so  that  the 
sheath  is  opened,  this  distal  swelling  is  entirely  absent,  and 
the  nerve  on  both  sides  of  the  lesion  is  slightly  sAvollen.  soft, 
and  reddened.  Upon  opening  the  sheath  of  a  nerve  that  was 
not  cut  by  the  shot,  one  frequently  finds  more  or  less  of  the 
contained  fibers  ruptured  with  scar  connective  tissue  between 
the  ends  of  the  fibers,  and  if  sufficiently  late,  the  beginning 
development  of  neuromata.  These  individual  fibers,  even  as 
the  whole  nerve  under  similar  circumstances,  must  be  re- 
sected and  the  ends  freshened  before  regeneration  is  possible. 
There  is  as  yet  no  diagnostic  method  of  determining 
whether  or  not  in  severe  cases  there  is  destruction  of  con- 
tinuity of  the  w^hole  nerve  or  only  of  some  of  its  fibers. 
Neurologic  examination  will  show  disturbance  or  absence  of 
functions,  and  in  cA^ery  case  of  absence  of  conductivity  the 
possibility  of  loss  of  continuity  must  be  considered. 


Kaiser,  F.  J.:  Neuralgia  After  Gunshot  Injuries  (Ueber  Neural^ien 
nach  Schussverletzuugen).     Beitr.  z.  klin.  Chit'.,  1915,  xcviii,  2.56. 

Kaiser  gives  the  histories  of  six  cases  of  neuralgia  after 
gunshot  injuries  of  the  limbs.  Four  of  the  cases  were  in  the 
median  and  two  in  the  sciatic.  In  all  of  the  cases  except  one 
there  was  a  mixture  of  neuralgia  and  neuritis.  One  was  a 
pure  neuralgia.  The  neuralgia  generally  begins  a  few  days 
after  the  injury  and  proceeds  slowly  without  any  thicken- 
ing of  the  nerve  and  without  any  trophic  disturbances  of  the 
skin.  The  neuritis  begins  immediately  after  the  injury  and 
disappears  sooner  than  the  neuralgia.  The  inflammation 
is  generally  only  perineuritic  and  does  not  cause  interruption 
and  destruction  of  conducting  nerve  fibers. 

The  treatment  is  tedious  and  consists  of  hot  air,  hot  baths, 
massage,  and  electricity.  Good  results  were  obtained  from 
the  injection  of  1  per  cent  novocaine  and  adrenalin,  follow^ed 
by  massage;  injection  of  fibrolysin  into  the  scar  was  also  of 
value.  When  these  methods  were  not  effective  (two  cases) 
the  nerve  w^as  laid  bare,  freed  from  cicatricial  tissue,  and 
sheathed  in  a  flap  of  muscle.  Stoff'el  has  recently  ])ublislied 
an  article  showing  the  positions  of  the  limbs  in  which  the 
nerves  are  under  tension  and  in  Avhich  they  are  relaxed.  In 
these  cases  the  limbs  wei'e  held  in  tlie  characteristic  positions 
foi-  relaxation  of  the  nerves. 


356  WAE    SUEGEEY    OF    THE    NERVOUS    SYSTEM. 

Borchardt:  Report  on  Gunshot  Injuries  of  Nerves  (Ueber  Scliusse 
insbesoiidere  Hpatchirui-gie).  Report  to  the  Secoufl  German  Sur- 
gical Cougress.  BeUraege  zur  Idin.  Cliir.,  Bd.  V,  Hft.  1,  Kregs 
CMruryisorc  Hefte,  1916. 

Borchardt  considers  the  treatment  of  gunshot  injuries  of 
the  peripheral  nerves.  The  indications  for  operation  he 
states  as  follows: 

Every  case  of  severe  nerve  injury  should  be  operated,  and 
operation  should  be  done  upon  the  grounds  of  jrindings,  not 
upon  the  course  of  the  recovery.  The  symptom  complex 
which  he  characterizes  as  distinguishing  severe  injury,  is  the 
following:  Total  failure  of  function  of  the  nerve,  motion 
and  sensation  gone,  trophic  and  vasomotor  disturbance,  and 
complete  reaction  of  degeneration.  If  there  is  only  partial 
reaction  of  degeneration,  he  does  not  operate,  only  Avhen 
there  is  no  longer  any  improvement  or  where  there  is  de- 
cided symptom  increase.  When  there  is  complete  loss  of 
function  of  the  nerve,  it  is  impossible  to  distinguish  whether 
the  nerve  is  completely  divided  or  whether  there  is  simply  a 
lesion  interfering  with  the  conductivity  of  the  nerve,  and  for 
the  surgeon  it  is  not  necessary  to  distinguish.  If  the  case 
is  one  of  severe  injury  in  the  above  sense,  it  should  be 
operated  as  soon  as  the  condition  of  the  wound  permits.  One 
can  not  determine,  by  electrical  examination  whether  tJie 
nerve  is  torn  or  not.  It  is  often  quite  difficult  to  make  a 
differential  diagnosis  between  psychic  paralysis  and  actual 
nerve  lesion.  In  these  cases  electrical  examination  is  of 
highest  worth. 

Borchardt  believes  in  early  operation,  and  he  cites  one  case 
which  he  operated  14  days  after  the  injury  with  good  results, 
but  on  the  average  he  recommends  the  sixth  to  the  eighth 
week  as  the  proper  time,  because  earlier  than  this  the  symp- 
tom complex  is  not  distinctly  developed,  and  the  condition 
of  the  wound  seldom  permits  observation.  From  a  purely 
technical  standpoint  everything  argues  for  early  operation. 
The  earlier  the  operation  is  done,  the  easier  is  the  opera- 
tion, because  dense,  extensive  scars  have  not  yet  formed,  and 
it  is  much  easier  to  loosen  the  nerve  than  at  a  later  date.  The 
longer  the  nerve  is  compressed,  the  longer  foreign  body  lies 
in  the  nerve  trunk,  so  much  worse  is  the  prognosis.  The 
longer  a  nerve  remains  nonconductive  the  longer  it  will  re- 
quire for  a  resumption  of  its  physiological  function.  Further 
than  this,  early  operation  will  in  a  measure  avoid  contrac- 
tures and  atrophies  in  muscles,  bones,  and  joints,  which  are 
bound  to  occur  if  operation  is  delayed  very  long. 

How  long  shall  one  wait  for  a  possible  spontaneous  re- 
covery of  function?  This  is  a  difficult  question.  One  case 
was  seen  in  which  one  and  one-half  years  after  the  injury 
the  first  signs  of  regeneration  were  observed.  Borchardt  is 
well  aware  that  an  early  operation  may  interfere  Avith  be- 
ginning spontaneous  regeneration,  but,  all  in  all,  he  believes 
that  the  sixth  to  the  eighth  Aveek  is  the  proper  time. 


FOREIGN  WAR  liti<:f^ature,  357 

He  agrees  with  Wilms,  in  so  ftir  as  recommending  the 
operation  upon  exploratory  grounds,  but  he  has  found  in 
somewhat  more  than  half  the  cases  that  nerve  suture  or 
other  nerve  operations  are  necessary.  On  this  account  he 
intimates  that  nerve  injuries  should  be  collected  under  the 
treatment  of  men  who  have  given  the  subject  special  study. 

Borchardt  does  not  believe  that  primary  union  of  a  di- 
vided nerve  is  possible,  and  l)elieves  that  in  any  case  there 
is  a  degeneration  of  the  peripheral  portion  of  the  nerve  and 
that  regeneration  occurs  by  the  axis  cylinder  growing  to- 
ward the  peripher}^  from  the  site  of  division. 

Borchardt  operates  in  a  bloodless  field,  secured  by  con- 
stricting bandage,  because  one  must  be  able  to  recognize 
the  anatomy  most  accurately.  If  the  nerve  is  divided,  the 
ends  should  be  freshened  sufficiently  to  remove  all  scar  tis- 
sue, and  the  nerve  should  be  sutured.  The  direct  suture  is 
the  ideal  operation  to  secure  conductivity  of  the  nerve. 
The  finest  silk  sutures  are  passed  through  the  perineurium 
and  corresponding  bundles  are  brought  into  approximation. 
He  relies  upon  the  microscopic  relationships.  In  the  ma- 
jority of  cases  direct  suture  is  possible.  In  cases  of  large 
defects  it  is  sometimes  possible  by  making  large  exposure 
of  the  central  and  peripheral  stumps  to  stretch  them  suf- 
ficiently to  bring  them  *  together.  In  some  cases  he  has 
even  left  some  scar  tissue  if  there  appeared  to  be  slight  ten- 
sion upon  the  sutures.  When  the  gap  is  too  large  to  allow 
the  ends  to  be  brought  together,  then  Borchardt  prefers 
implanting  the  two  ends  into  a  neighboring  nerve.  He  is 
not  inclined  to  bridge  the  gap  with  foreign  material.  He 
favors  inclosing  the  suture  with  material  to  prevent  ad- 
hesions, when  possible. 

The  period  after  which  regeneration  begins  to  manifest 
itself  varies,  and  possibly  not  before  one  or  two  years  can 
one  tell  whether  regeneration  will  be  complete.  Several 
factors  interfere  with  good  results.  The  most  common  is 
that  resection  of  the  ends  is  not  sufficient,  scar  tissue  re- 
maining upon  the  central  and  the  peripheral  stumps. 
Another  possibility  is  that  during  the  after  treatment  brisk 
movement  causes  separation  of  the  sutured  ends  on  account 
of  tension.  Third,  is  the  compression  of  the  nerve  by  ad- 
hesions and  portion  of  scar  tissue. 

In  all  these  cases  a  renewed  operation  is  certainly  indi- 
cated, but  one  should  not  repeat  the  operation  too  early. 
In  this,  all  are  agreed.  In  no  case  should  one  reoperate  un- 
less there  is  absolutely  no  sign  of  regeneration  for  a  half 
year  after  the  primary  operation.  In  general,  it  is  much 
better  to  attempt  first  to  resuture  the  nerve  before  imder- 
taking  muscle  or  tendon  transplantation. 


358  WAR    SUEGERY    OF   THE    NERVOUS   SYSTEM. 

Ernst  Miiller:  Utilization  of  the  Elasticity  of  Nerves,  etc.  (Ueber 
die  Ansuutziing  tier  Dehubsirkeit  des  Nerveu  Durch  Temporare 
Verkoppelung'  bei  Grozen  Defekten  zuiii  Zweck  der  Nervenuaht). 
Britmgc  zvr  Klinischen  Chiniroie.  (KrleqHchiruryisfhes  Heft 
XXX-XXXIV.)     April,  1917,  p.  651. 

Miiller  has  encountered  several  cases  Avhere  there  M^as  a 
considerable  gap  between  the  nerve  ends  to  be  approxi- 
mated, so  that  direct  suture  could  not  be  carried  out.  In 
such  cases,  several  procedures  have  come  to  be  recognized. 
These  he  considers  in  the  following  order : 

(1)  Implantation,  in  which  the  nerve  ends  are  implanted 
into  a  neighboring  nerve.  In  some  instances,  instead  of 
the  implantation  of  the  peripheral  stumps  into  another 
motor  trunk,  both  stumps  are  implanted  into  the  same 
nerve  trunk.  (2)  Interposition  of  nerve  substance  may 
also  be  done  by  interposing  a  flap  from  the  peripheral 
stump.  Free  transplantation  of  nerve  tissue  may  also  be 
done  and  interposition  of  foreign  material,  such  as  catgut, 
has  also  been  done.  (3)  Regeneration  can  also  be  ac- 
complished by  inclosing  the  two  stumps,  either  in  empty 
tubes,  or  filled  tubes.  The  tube  may  be  of  decalcified 
bone,  rubber  dam,  magnesium,  or  calves'  arteries  hard- 
ened in  formalin.  Tubes  of  these  same  materials  may  be 
filled  with  blood  vessels,  with  serum,  with  gelatin,  with 
blood,  or  agar.  In  certain  instances,  tubes  have  been  made 
of  fascia  and  of  fat. 

Miiller  has  devised  the  following  method  for  approxi- 
mating the  separated  nerve  ends:  The  limb  is  so  flexed 
as  to  relax  the  nerve  to  the  greatest  possible  degree  and 
the  nerve  ends  are  approximated  as  closely  as  possible  and 
held  in  this  position  by  means  of  a  strip  or  tube  of  fascia. 
After  wound  healing  has  been  completed  and  the  nerve 
ends  fastened  by  the  fascia,  the  limb  is  then  gradually  ex- 
tended, even  over-extended.  The  nerve  trunk  possesses  a 
certain  degree  of  elasticity  and  lengthens  owing  to  the 
stretching,  and  at  a  second  operation,  by  forcibly  flexing 
the  limb,  very  often  the  nerve  ends  can  be  directly  sutured. 


von  Lorentz:  Nerve  Injuries  and  Their  Treatment  ( Nervenverlet- 
ziiugeii  xind  Deren  Behandlung).  Beitrage  zur  Klinischen 
Chirurgie  Vierter  Kriegschirnrgischer  Band.  ( Kriegschirurgi- 
sches  Heft  XTI.)     .July,  1916,  p.  248. 

It  has  been  estimated  that  1^  per  cent  of  the  injuries 
produced  in  modern  warfare  are  complicated  by  injuries  of 
the  peripheral  nerves.  It  would  be  well  for  the  surgeon 
on  the  front  to  remember  this  and  in  applying  first  dress- 
ings to  consider  the  immediate  and  the  late  treatment  of 
nerve  injuries.  Many  of  the  injured  themselves  recognize 
that  a  certain  part  of  the  body  is  paralyzed,  but  the  well- 
trained  surgeon  will  always  think  of  the  possibility  of 
nerve  injury  and  conduct  his  examination  accordingly. 


.      FOREIGN    WAR    LITEBATUEE.  359 

When  nerve  injuries  are  recognized,  the  dressings  and 
splints  must  be  so  applied  as  to  render  subsequent  treat- 
ment for  a  nerve  injury  most  favorable.  It  often  hap- 
pens, through  neglect  of  this  point,  that  limbs  are  left  in 
such  position  that  the  nerve  ends  purposelessly  are  sepa- 
rated by  5  or  6  cm.,  and,  further,  that  joints  are  allowed 
to  ankylose  in  the  most  useless  position — for  instance,  the 
median  nerve  forms  a  bend  in  the  elbow  and  at  the  hand  and 
finger  joints.  An  injury  of  the  musculo-spiral  should  call 
for  bending  of  the  elbow  and  the  overextension  of  the  wrist 
joint.  In  no  case  should  the  paralyzed  muscles  be  allowed 
to  be  rendered  useless  by  overextension. 

Great  difficulty,  even  with  the  most  accurate  neurologi- 
cal examination,  may  be  exj^erienced  in  attempting  ac- 
curate localization  of  the  lesion.  The  electrical  reaction 
renders  great  assistance,  especially  when  there  is  com- 
plete division  of  the  nerve  trunk.  When  the  lesion  is  not 
complete,  the  picture  is  more  complicated. 

As  to  the  question  of  operation,  Lorenz  has  adopted  the 
rule  in  all  cases,  even  in  light  injuries  which  do  not  show  a 
tendency  to  improve  within  three  or  four  months,  to  make 
an  exploratory  operation.  Also,  where  the  progress  has 
been  satisfactory  for  three  or  four  months  and  then  there 
is  recrudescence  of  symptoms,  and  also  where  there  is  a  dis- 
tinct lessening  of  electrical  excitability,  operation  is  indi- 
cated. Another  indication  for  operation  is  severe  neural- 
gias, which  are  limited  to  the  distinct  nerve  distribution. 

It  should  be  emphasized  that  no  nerA-e  operation  should 
be  undertaken  until  the  wound  is  completely  healed.  To  op- 
erate through  granulating  tissues  is  to  court  disaster.  Even 
completely  healed  wounds  may  often  harbor  bacteria  (latent 
infection),  which  become  virulent  after  operation. 

Lorenz  advises  against  the  application  of  Esmarch  ban- 
dage during  operation.  He  objects  upon  several  grounds: 
(1)  That  the  nerve  may  be  actually  injured  by  constrictor 
long  applied;  (2)  that  the  nerve  conduction  may  be  inter- 
fered with  during  operation,  and  on  this  account  the  con- 
ductivity of  the  nerve  can  not  be  ascertained  during  opera- 
tion ;  and,  finally,  that  the  blood  supply,  being  cut  off  during 
operation,  an  unnoticed  hemorrhage  may  occur,  with  hema- 
toma formation  after  the  woitnd  is  closed. 

The  question  of  anesthesia  is  not  usually  easily  decided. 
These  operations  are  usually  tedious  and  prolonged.  On 
this  account,  general  anesthesia  has  a  distinct  advantage, 
while  local  anesthesia  usually  will  not  last  for  an  operation 
of  long  duration. 

The  character  of  operation  depends,  naturally,  upon  the 
character  of  injury.  It  should  be  generally  advised,  how- 
ever, that  the  operation  be  quite  radical.  The  incision  should 
be  sufficient  to  permit  of  good  exposure  of  the  nerve,  not 
only  at  the  site  of  injury  but  for  several  centimeters  above 
and  below.  It  is  often  also  necessary  in  order  to  permit 
mobilization  of  the  nerve  ends.     It  will  be  often  necessary, 


360  WAR   SUEGERY    OF    THE    NERVOUS   SYSTEM. 

on  account  of  scar  tissue  or  callus,  to  resect  the  nerve  ends, 
or  the  nerve  ends  may  be  found  separated.  The  approxima- 
tion of  the  nerve  stumps  should  always  be  possible  after 
good  mobilization.  Certain  positions  favor  this  by  decreas- 
ing the  tension  of  the  nerve  trunk.  The  suture  should  in- 
clude just  perineurium,  and  care  should  be  taken  to  avoid 
rotation  of  the  stumps,  thus  insuring  direct  contact  of  the 
corresponding  bundles. 

Subsequent  adhesions  at  the  site-  of  future  should  be 
guarded  against  in  one  way  or  another.  Several  methods 
are  recommended  for  this  trouble,  the  most  rational  being 
the  inclosing  of  the  suture  line  with  an  autoplastic  fat 
transplant. 

One  method  of  approximating  nerve  ends  that  are  widely 
separated  is  that  of  resection  of  a  piece  of  bone.  This  is 
hardly  to  be  recommended  in  every  case.  In  large  nerve 
trunks  direct  suture  may  be  possible  through  plastic  opera- 
tions, similar  to  tendon  lengthenings.  The  old  method  of 
nerve  implantation  (i.  e.,  the  implantation  of  a  peripheral 
nerve  stump  into  another  peripheral  motor  nerve),  may 
still  be  employed,  often  with  good  results. 

Primary  healing  of  nerve  suture  is  a  ver}^  important  con- 
sideration in  the  result.  A  correspondingly  careful  after- 
treatment  is  also  of  the  greatest  importance.  Care  should 
be  taken  to  avoid  tension  on  the  nerve  ends  by  keeping  the 
joints  flexed  in  the  most  suitable  position,  and  dressings 
should  remain  in  place  until  healing  is  complete.  The  para- 
lyzed muscles  should  be  brought  into  such  position  that 
there  will  be  no  overstretching,  and  atrophy  should  be 
guarded  against  by  means  of  massage,  electricity,  and  hot- 
air  baking.  Care  should  be  exercised  in  baking  on  account 
of  the  diminished  sensibility,  which  might  lead  to  severe 
burns. 

The  prognosis  in  nerve  suture  depends  upon  the  type  of 
operation,  the  after  treatment,  and  particularly  upon  the 
location  of  the  injury.  Plexus  injuries  and  injuries  of  the 
more  central  portions  of  nerves  offer  in  general  a  much 
more  unfavorable  prognosis  than  the  more  peripheral  in- 
juries. 

o 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

....   —                   J 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

1 

OV   2  5    IQAf 

1 

■J 

IM4     M 

! 

C28(239)M100 

ED  59  3 


IJn3 


U.S.    Surgeon  general's  office 
ViTar   sur="erv  of  the  nervous   system 


^OV'25  1940 


/ 


^O^U^flBlAUNWERSlTY  LIBRARIES  (hsUtx) 

RD593Un3C1     ,    ,^,em 

^Ifiilif" 

2002269066 


